GW1--04997_Well Construction - GW1_20240828

WELL CONSTRUCTION RECORD For Internal Use 0NWN
Tins form can be,rsod fiw single or multiple Hells
I.Well Contractor Information:
14.WATER ZONES
Chris Ruffer nnOM ToDrS('RIPtION
Wdl Contractor Nana ft. ft.
4223 A II, ft.
NC Well Comactor Certification Numbet i IS,OUTER CASING(for.lulll- d eel OR LINER(W 1
'Host TO nuMrtrR T1IICENTSS M4TTeul
SARDACCO R. n. in.
Conpoal Name If.INNER CASING OR T URING isrilitratat n eedaatp) f
mow TO , nl%'.9itn 1 110(A.F.1 .It110\I
2.Wdl Condrlcdua Peewit Y: 2024-19-06-MW3-RWO 0 ft. 40 ft, 1 2 its SCH-40 PVC
tie. S..".,.. i !�'dDdl IS,
0 n. 5 II. 2 ill. SCH-40 PVC
3.Well I-is tihed:well use): ' 17.St-RUN — -
W'aterSupph Well: mud TO DI-.rtTTM JSLOT E1I7 THKKNRss Mstrul AL
LiAgrwultutal OMtmicipal'Publlc 40 ft. 50 R. 2 10• 010 SCH-40 PVC
❑Geothemul(NeatinglCooling Supply) Oftesidentral Water Supply(single) 5 A 15 ft, 2 is. 010 SCH-40 PVC
taghc)
OlndustlialiCommcrcial OResidctttial Water Supply(shared( la,GROUT
FROM ..-. R1... ._...... MATERL.I. EMPLACEMENT METHOD I AMOUNT
❑Imps ion 0 II. 2 fl. Portland Pour
Non-Water Supply Well: -.__ ..
(i. n.
RMotutonng ORecow:ry .
n. a
Injection Well:
. 1
L'Aquila Recharge ❑Groundwater Rcmediation l7.SAND+t:Itt,VEL PACK lit applicable'
WHOM 10 SlaTRR111. _ TMPI.a(TVr.NT Mr.TRCID
I:Aquifer Storage and Rccocen ❑Salinih Darner 38 ft. 50 ft. Sand #2
CI Aquifer Test ❑Slomn.:ttcr Drinaet 3 R. 17 ft. Sand - #2
❑E.pcnmcncrt Technologs ❑Siihsidcm c Comm! .
24.DRILLING LOG Wadi additional speeds if theceear.J
❑Gcothcmul lCIused Loup i ❑Tracer raoM To Der'Rnnu.tenI.r,h.b.r•..,o.Ilw,-I tont.rra..w•.r«I
OGcoihcntal(HeatinglCoolitig Room t ❑Other(explain under 021 Rematta) n. n.
ft. ft. -- _
4,Date WeN(s)Completed: 7-23-2024 wj wilt1t-17DiS
—
Sa.Wdl Location: n. ' Sea GEM'a Notes
Sherwin Williams n. ' It
i
F.actlits tlw ter Name F.icilm Itlkiifapplicable! _
t1 It. IG%r:i:...: . ,aa--
-s Jr
113 Old Stage Coach Trail, Greensboro, NC, 27409 i ' '',faRr.,-;j
Ph'"cal Addles'-Cit .and ZIP r 21 REMARPO.
Guilford Nested well; bentonite seal from 17-38'
Otoul)-._-_-------...--... I'.tnd It M*tratlun No IPINt
Sb.Latitude and latn>:itude in degrees/minutes/seconds or decimal degrees:
Of sell raidc a I,nc lahmg is slit iictni 22.I'CI'tlleC'-[inn.
t, w Chris Ruffer 7/26/2024
Sigrwtan:of(Coined Well Cottimniot Dote
6.Is(are)the%ellls): 20Permanent or OTettperar7'
M won)/*LI hsntr.1'kerb.certify that the wrll(rh war tercel avmrmn'red is axmdamr
With 1 SA NC.4C 02C.0100 or 154 NCAC 02('.0200 Well Cawsfrw'nirn Stimulants anal that a
7.la this a repair to an existing well: OYes or EN* copy of thu recant has been primiled to the twit aware
if tlrls II n tepulr,!What l nowt1 w cll..mauve hem utfornwrtam,u+,l e',pled,i the etrare of the
repair ander I21 resiartt mniwn or on the bait of this form. 23.Site diagram or adtiltisoal well details:
You mat use the back of dies page'to pros(de additional well site details or well
8.Number of well',imasInseted: 2 cxnintmcuun details. You mm also attach:skimmed pages if necessity.
fur mab,plr nr;r•.non,a,,,oI-ewe-r,uppft wells ONLY malt ft,..Janet c,ta9rartaar ,.::,,;,.r
.'-aims raw Jong. SUBMITTAL INSTUCTIONS
9.Total well depth helm lard surface: 50 and 15 (fy.) 24a. For All Wells Submit this form ttuhur ltl dins of completion of sell
f,., , , ,.,•',Mist te0its„.;,,ifdtferrnrlelovi,f.-. ire'IYiWa Ali'4.trait constnidiontotl(cfollonitag
lii.Static water ksel lulus top of casing: (IY.) Division of Water Resources,Information Processing t sit.
if*Wier level 11 above camas:.use ♦ 1617 Mail Service('enter,Raleigh,NC 27699-1617
I I.Borehole diameter:8.5" nit.) 24h.Fur lujeijion Welb ONLY: hi addition to sending the form to the address in
24a abuse. also submit a copy of this form within 30 dins of completion of well
12.Well eunslruOtisn method: Sonic cotisltuc ion to the following.
,i c.anger.roan.cable direct push et.1
Disision of Water Resources,underground Injection Control Program.
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center.Raleigh.N( 27694-1636
t3a \'itid Ig(util �Icthml of rest tie.For Water Suppis tic Injection Welts:
Also submit one cop y of this form cithut IO day s of conlpleiion of
13h.Disinfection type. knonant: well construction to the counn health depsnment of the coons.where
conitnrcted
Fonn GW-1 North Carolina Ckpanmeni of Ens troiuiucm aunt Natural Resources-Division of Water Realise Rcs wed At6t61 Sol 4