GW1--05322_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.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
4356
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Summit Design and Engineering, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
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,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): rt. ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public 65.0 ft. 80.0 it 2 in' 0.010" PVC
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
Industrial/Commercial 0Residential Water Supply(shared)
18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft, 60.0 ft cement-bentonite grout
x Monitoring 0 Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Q Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage 60.0 ft• 80.0 ft• No.2 Sand
Experimental Technology 0 Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed:8/11/23 Well ID#B-50D ft. ft. jo''� _
5a.Well Location: ft. ft. 1 r-��� f `+
A-1 Sandrock `�L ' f t'
ft. ft. p A
SE
Facility/Owner Name Facility ID#(if applicable) ft. ft. r O `r 2oZ7
2091 Bishop Road, Greensboro 27406 ft. ft. Inidmi.iien Prr.� •
Physical Address,City,and Zip ft. ft. d'hiC� -
Guilford 21.REMARKS -
County Parcel Identification No.(PIN) Well Pad and Cover Installed
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latflong is sufficient) 22.Certification:
35.987476 -79.844697 W
6.Is(are)the wells) Permanent or x�Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes orON0 with ISA NCAC 02C.0100 or ISA 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 a2/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 1 GW-1 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 land surface: 80.0 ft
P ( ) 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@I00)
construction to the following:
10.Static water level below topof casing:23.1 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:2.5ii n.
(i ) 24b. For Injection Wells: In addition to sending the form to the address in 24a
auger and NQ2 Wireline Core 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 Sum*& Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13h.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016