GW1--03385_Well Construction - GW1_20240610

WELL CONSTRUCTION RECORD For Internal Ilse ONLY.
This form can be used for single or multiple wells
1.Well Contractor Information:
Lawrence D. Opper 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
NC3322-A ft. ft.
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
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): t7.SCREEN
Water Supply Well: FROM TO DIAMETER_SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 15 fL 30 ft• 2 In. .010 sch40 PVC
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM J TO MATERIAL. I EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. ft.
3 Cement pour
Non-Water Supply Well:
OMonitoring ❑Recovery
3 ft 13 ft. Bentonite pour
Injection Well: ft. ft.
-J
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD _
13 ft' 13 ft. #2 sand prepack/pour
❑Aquifer Test ❑Stormwater Drainage -
ft. ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary) -
OGeothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 24 fa reddish-brn silt and clay
5/7/2024 MW-1A 24 ft 30 ft- Weathered Rock or saphrolite
4.Date Well(s)Completed: ft. ft.
5.Well Location: ft. ft.
Church Street Family Fare/BP#172 ft. ft. * N C y$
Facility/Owner Name Facility ID#(if applicable) ft. ft.
` `v 1: Las
2750 North Church Street, Greensboro ft. ft. 11 IN 1 8 2D24
Physical Address,City,and Zip 21.REMARKS -
Guilford 17t&nt;1 (jlrl
ow,,
104
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: (1 Y
(if well field,one lat/long is sufficient) 11J
36.115986 N 79.781897 W Lawrence Opperg-- :�°,,;°;� �
, �-- . 5/14/2024
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,/hereby certify 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 ENo 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: 30 (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 top of casing: approx 23 (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: 3•50 (in.) 24b. For Injection Wells: In addition to sending the form to the address in 24a
Geo robe- DP above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: p 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
136.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