GW1--01761_Well Construction - GW1_20240320

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WELL CONSTRUCTEON RECORD �\ For[dental Use.ONLV:
Thu Cancan be used for single or multiple(yens•
I.Well Contractor Information: 1
CLr:,WATER ZONES
Brian Ewing . FROM 70 DESCRIPTION
Well Co lot Name ft. ft: I • •
4240-B ft. it.
NC-Well ConlydclorCcnification Nanilcr 85,OUTER CASING(Memel OR-LINER(Waif ncabk):
FROM TO DTAMETI'R• THICKNESS- MATERTAL•
•
SAEDACCO iL ft. in.
Company Name I6.-INNER'CASING OR TUBING .aeticrmat d p osed-lou
•FROM TO DIAMETER THICKNESS MATERIAL
2.WcllConstructionPeu'tnitit. 2024-28-02-MW4-RWO 0 R. 5 ft, 2 i 'in. SCx-40 PVC
List ail a fit Jk well pc-hail-1(ix.Comity,Suite,.Varinnrr.fi je 'CAt elc.) -- - - .
-It. ft. in.
3.Well-Ilea(check wcltuce: • c1 SCREEN
Water Supply Well: FROM TO DIAMETER. SLOT Sin. TRICKINESS I MATFRIAI.
15Agiiculwral DMunicipabPnblic 5 R. 10 It. 2 in 010 SCH-40 PVC
DGeotlicmial(Heatingi•'Cooling Supply) ❑Residential Water Supply(single)• - R. ft. in. . 1
®industriaUContotcrcial ©Rcsidential Water Supply(shared) :tut:GROUT
FROM 70. JTATERthL EMPLACEMENT MF IIIOD AMOUNT i
' ❑Irtigation 0 ft. 1 - ft. PORTLAND POURED
Nou-Water Supply Well: - •
q, t.
WMonitoiing - . DRccovcuy , • .
•Injection Weil:. .ft, R.
ElAquifcr RcclitirgC` lDCioundwatcrRentetir:10 n t9:'SANOIGRAVEL PACK(if ataplt sbte)- 1
-FROM' • TO MATFRrAI. EMPLACEMENT METHOD
IDAquiferStoragc and Rccove4' • I3Salinity Hamer 3 R. 10 ft, FILTER SAND # 2
❑Aquifer Test ElS(orrnwatcr Urti'oge R. It..
DExporimcntal Tcclinology' ❑Snhsidcncc Control . • -
2or DRILLING LOG(attach.additional sheets if necessary'
❑Cn otltetnwl(Closed Loop) OTrlcer - .FROM• r0 DESCRIPTION(color.h;rn[ner;warn kni,c.earid 4te,cit.}' .
❑Geodtetivalti3eatineiCoolingRetum) . ❑0tiler(explain under ll2l Rethinks) 0 •ft. 5 ft, FILL SILT AND SAND
5 ft. 10 ft. SILT CLAY MOIST TO WET'
4t.Date We(ls)Completed: 3-4-24 Well lI WMW-04 rft ft.
5a.Well Location: .ft R. -
Innospec Performance Chemicals - R. ft, t. 6 -
Faet1ity,Osy[rrNui>tir Facility 1Dk.(i£appliable) ft: ft. MA �" `"
510 W. Grimes Ave., High Point, NC, 27260 ft. ft.: �r a �
•
Plrysical Address..City.and Zip ;21:1tLM IRKS; ln;J:,,,,,... •-e,
Guilford BENTONITE_ 1 TO 3'. Liss....,....;�~
•
Coolly Parcel tdcntitielliun NO.(PIN)
Sb.Latitude alid'Longitude in ifegrecsiminutesluctlnds or dceintal dcgu.-es. 22.Ccttiiieatinn:.
(Buell fiild,ow huiloisg 15'Su il'ielenl) .
RR.ri• •
B
N NY a, ,,Ewing. 3,8,2024
' - Signturc of Cenificd Well Contractor Dale •
. 6.Is(are)the w•ell(s):-BIPern anent. or' ❑Temporary ,
1R•s,gnigg thin form,1 hereby certify Mat lhx ne t's)uses(myth cYrr_xtructed iTheeorrfuncr
with l51 NCAC 02C.0100 or ISA NC1IC-02C.0200 Well Constrstction Standards and rlarir a
7.Is this a repair to an existing well: ❑Yew or BIND copy of rtik rrconilins•Item provided to;he well mener,
1f rids is o..•pale;fall an;fintibit will naruttiretion.lnfanrsetl nn and tsplahr the'Ware of rho
repair dirdcr 021 mnard'.r srrlioo or wi the bait of thit form. 23.Site diagram or additional wellderaiCs:
You may use the back bf this page CO provide additional well site details or well
S.Number of wells constricted: 1 construction details, You-may also attach additional pages if nc':essan^.
For oraldpte iirJecilon or non-miser supply wells ONLY wide die sane coiratruttlon,volt can
submitone form. ' StiRMCr7AL iNSTUCTIONS.
9.Total well depth below Land surface: 10 (ft,) 21a. Fur All Wells: Suhntit this font within 30 days of conip(etion of well
For whiffle ivellslisr all depths Ifditivau(crontplr-.a,2kt'chid 2u?100) conslmctiontothe rollout ngg;
10.Static water level below top of casing: (Pt) Division of Water Resources,Information Processing Unit,
If water keel is above Busing,use"+" - - 1617 Mail Sery ice Center,Raleigh,NC 27699-1611
IL Borehole diameter:8'25" (ia.) tab.For infection Weill ONLY: in addition to sending the fort to the address in
24a abiive.also submit a copy of this Ifortu within 30 days of completion of sell
12.Well constittction method:BORED cotlstmctlou to the following i
tie.auger.rotas}•,cable direct push.etc.}•
Division of Water Resources,Uuderg'ound Injection Control Progratu;
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center.Raleigh,NC 27699-1636
i
13 r Yield(glum) Method of test: 24e.For Water Supply&Injection Wells:
Also submit one copy of this form within 30.days of completion of
13h.Disinfection type: Amount: well construction to the county health department of the cotinty.whcre
consinected. f •
Form GW-1 Mtnik CarolinaDepMmern of Eneironnrtu ant Natural Resources-Division of Wally ReatTCES I Revised August InI3
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