GW1--01358_Well Construction - GW1_20240304

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: ,
Lawrence D. Opper 14.WATERZONES e,
PP FROM TO DESCRIPTION
Well Contractor Name ft. ft.
•
NC3322-A ft. • ft. I '
•
NC Well Contractor Certification Number I5..OUTER CASING(for muld-cased wells)OR LINER(if ap'limbic) _ _
FROM TO DIAMETER' THICKNESS MATERIAL
Regional Probing Services ft. ft. in.
Company Name 16.INNER CASING OR TUBING"(geothermal closed-loop)" _`` '
FROM TO DIAMETER THICKNESS MATERIAL --
2.Well Construction Permit#: 0 ft• 15 ft• 2 .in. sch 40 • PVC
List all applicable well construction permits(i.e.County,State,Variance,etc.) - •
ft. ft. in.
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO , DIAMETER SLOT SIZE THICKNESS MATERIAL
ID Agricultural ❑Municipal/Public • 15 ft. 35 ft. 2 '"' .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
FROM _ TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft• 3 ft• cement grout pour
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft• 13 ft• bentonite prepack/pour
Injection Well: ft. ft.
❑Aquifer Recharge El Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable) '
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Sal inity Barrier 13 ft. 35 ft. No.2 Sand prepack/pour
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology 0 Subsidence Control
'20.DRILLING LOG(attach additional'sheets if necessary) ` - ,
0 Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 35 ft• Orange%tan silty Clay over tan-brn silty Sand
4.Date Well(s)Completed:
1/30/2024 MW-1 ft. ft.
ft. ft. I
5.Well Location: ft. ft. C"-O i %f,
Guilford College Family Fare ft ft. � '^�- �; ' •-
Facility/Owner Name Facility ID#(if applicable) ft f[ M Al� 0 4 2024
628-Guilford College Road, Greensboro ft. ft. tn;orzlaii. ,I•r,� c•es Cam:
Physical Address,City,and Zip `2CREMARKS° ' • ' ' •. i`Cti t h
Guilford
County Parcel Identification No.(PIN) i
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: PI
(if well field,one lat/long is sufficient) rlg'.dlyslgne•. .wrensoOpper
,�r w cn=Lawrence Opper,o=Regional
36.063782 N 79.907310 W Lawrence Oppe -gServires,ou,pmbing.com,c US 2/12/2024
Del..2019.02.04093952 05'00'
Signature of Certified Well Contractor ' Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certifr that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ❑No copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. 24.Submittal Instructions: , ,
9.Total well depth below land surface: 35 (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 tt 00'and 2@100') construction to the following:
10.Static water level below top of casing: approx 28 (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4.25 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Auger DP above, also submit a 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.)
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: • 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply&Geothermal 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 Environment and Natural Resources-Division of Water Quality Revised Jan.2013