GW1--05321_Well Construction - GW1_20240906

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Michael B. Moseley 14.W'ATERZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
4356 •ft. ft.
NC Well Contractor Certification Number 1S.OUTER CASING(for multi-cased wells)OR LINER(if ap livable)
Summit Design and Engineering, Inc. FROM TO DIAMETER THICKNESS MATERIAL
------ - H. ft. in.
CompanyName
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Slate,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E3Municipal/Public 15 ft. 30.0 ft 2 in' 0.010" PVC
Geothermal(Heating/Cooling Supply) 0Residential Water Supply(single) ft ft. in. -
Industrial/Commercial OResidential Water Supply(shared)
1&GROUT
irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 it 12.0 ft bentonite chips
X Monitoring 0 Recovery ft. ft.
Injection Well:
fc ft.
Aquifer Recharge 0Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery D Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test D Stormwater Drainage 12.0 ft 30.0 ft No.2 Sand
Experimental Technology 0 Subsidence Control ft. ft.
Geothermal(Closed Loop) D Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size etc.)
fL ft.
4.Date Well(s)Completed:7/31/23 Well ID#B-49 ft. ft. �: •-
5a.Well Location: ft. ft. `�0 L`; / i' }
A-1 Sandrock ft. f`. SEP 0 6 2024
Facility/Owner Name Facility iIN(if applicable) ft, ft.
2091 Bishop Road, Greensboro 27406 ft. ft. lac)'T.‘ioen Orr,r .,,2 upa
Physical Address,City,and Zip
ft.ft. RWNCA1
Guilford 21.REMARKS
County Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.989362 -79.844352 W
6.Is(are)the well(s)UPermanent or X[Temporary Signature oCCertifie ell Contractor Date
By signing this form,i hereby certt&that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or X3No with/5A NCAC 02C.0/00 or I5A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under 112/remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only i GW-i is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below!sod surface: 30.0 fL
P ( ) 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 2@I00') construction to the following:
10.Static water level below topof casing:29.5
(ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use" ' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:3.25 (in.) 24b. For Injection Wells: In addition to sending the form to the address in 24a
auger above,also submit one 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 Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply& Injection 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-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016