GW1--01048_Well Construction - GW1_20240212

I
r, Print Form ,
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: j
1.Well Contractor Information:
Terry White 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3 A ft f t.
287
ft. ft.
NC Well Contractor Certification Number
ET 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER,, THICKNESS MATERIAL
ft. ft +' in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop) -- - -
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) 0 fr. 10 ft 1 ! in- Sch40 PVC
3.Well Use(check well use): ft ft. m
17.SCREEN -
Water Supply Well; FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
Agricultural EiMunicipal/Public 10 20 ft 1 i°'4 ;0.010 Sch40 PVC
Geothermal(Heating/Cooling Supply) OResideatial Water Supply(single) ft ft. . in.
Industrial/Commercial DResidential Water Supply(shared) -
18.GROUT'
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
- Non-Water Supply Well: . - -- -- -- I - ft. 8 - ft• Bentonite Poured/10LB
Monitoring E3Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK(If applicable)
Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage 8 ft 20 ft. •
Experimental Technology EjSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
ft. ft
See Consultant Log
TMW-1 ft. ft 2/6/24
4,Date Well(s)Completed: Well ID# ft ft 7.
5a.Well Location: I...Li( { '
...s
Vacant Building ft. it
Facility/Owner Name Facility UN(if applicable) ft. ft. � F C 6 1 2 2024
514 S. Elm St. Greensboro 27406 •
ft ft i. tfltetara irsa,Pr,;; ;,,,u
Physical Address,City,and Zip ft ft. um/Boa
Guildford 21.,REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
36 04 00 N 79 47 28 W % Y 2/7/2024
6.Is(are)the well(s)rPermanent or x Temporary Signature of nified Well Contractor Date
By signing this form,I hereby certity that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ElYes or '% No with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may alsoattach additional pages if necessary.
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drilled:one SUBMITTAL INSTRUCTIONS I
9.Total well depth below land surface: 20 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following:
10.Static water level below topof casing:6.28
g (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:2 1/4 (in.) 24b.For Infection Wells: In addition to sending the fbrm to the address in 24a
Direct Push above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) s
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply&Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016