GW1--03384_Well Construction - GW1_20240610

WELL CONSTRUCTION RECORD RQV t .&4( f0 rVI.1
For Internal Use ONLY:
This form can be used for single or multiple wells � n v t O,•A f1J 1q 4
1.Well Contractor Information: `` 'C
Lawrence D. Opper 14.WATER ZONES \ `c e►c1d.c-es C
FROM TO DESCRIPTION ) •
Well Contractor Name ft. ft.
NC3322-A fL fL
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
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 rt. 25 rt. 2 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 DLAMETER SLOT SIZE THICKNESS MATERIAL.
❑Agricultural ❑Municipal/Public 25 ft 40 ft. 2 in.
.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 E.IPLA('EMENT METHOD&AMOUNT
❑Irrigation 0 ft. 3 ft. Cement pour
Non-Water Supply Well:
mMonitoring ❑Recovery 3 f`' 23 f`. Bentonite pour
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
23 f`• 40 ft #2 sand prepack/pour
❑Aquifer Test ❑Stormwater Drainage
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ft. II.
❑Experimental Technology ❑Subsidence Control _
20.DRILLING LOG(attach additional sheets if necessary)
❑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. 33 ft. Orange/tan-brn silty Sand
4/4/2024 MW-1A 33 f`• 40 f`• Weathered Rock or saphrolite
4.Date Well(s)Completed: ft. ft.
5.Well Location: ft. ft. ;7. i= 7:r% t1=r
Sedgefield Family Fare/BP#417 `I- , + V I.�'
ft. ft.
Facility/Owner Name Facility IDS(if applicable) JUN 1 0 2624
ft. ft.
4200 W. Gate City Blvd., Greensboro ft. ft.
Physical Address,City,and Zip 21.REMARKS i,.c.' 9,ci
Guilford
County Parcel Identification No.(PIN)
As i
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 7 i
(if well field,one lat/long is sufficient) 22.Certifcation:/ �'
36.037183 N 79.86215 `�. Lawrence Opp- :s7::� 4/21/2024
Signature of Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certifr that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E No copy of this record has been provided to the well owner.
Ij 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: 40 ((t,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2Q100') 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 5 (in.) 24b. For Injection Wells: In addition to sending the form to the address in 24a
Augerabove, 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 SUDDIv&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