GW1--05326_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.WATERZONES
Well Contractor Name ft
FROM TO DESCRIPTION
4356 ft.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap 'cable)
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. IBC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 0Municipal/Public 2.6 ft• 17.6 ft 2 '' 0.010" PVC
°Geothermal(Heating/Cooling Supply) D Residential Water Supply(single) R. ft. in.
JIndustrial/Commercial 0Residential Water Supply(shared) 18.GROUT
IlIrrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 it• 2.6 ft bentonite chips
Monitoring QRecovery ft. ft.Injection Well: -
ft ft
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage 2.6 R• 17.6 ft. No.2 Sand
Experimental Technology 0 Subsidence Control ft. ft.
Geothermal(Closed Loop) ID Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,Hardness,soilirork type,grain size etc.)
ft. ft
4.Date Well(s)Completed:7/26/23 Well ID#B-47 ft. ft.
5a.Well Location: ft. R. } :' �.. ' ,
A-1 Sandrock ft. ft. '1..... ; `/1....Li
Facility/Owner Name Facility ID#(if applicable) ft. ft. • S E P 0 6 2024
2091 Bishop Road, Greensboro 27406 ft. ft trriorr;84:0n tJ rrl
Physical Address,City,and Zip ft. ft. Dw OG '9 Otip
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:
35.987741 N -79.846311 W
tom./ d-1-Ay
6.Is(are)the well(s)f Permanent or xOTemporary Signature irCertified ell Contractor Date
By signing this form,1 hereby certi that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or x)No with l5A NCAC 02C.0100 or 15A 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''2/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: 1 7.6 t.f
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 24)100') construction to the following:
10.Static water level below topof casing: 10.3 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