GW1--05695_Well Construction - GW1_20240920

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Ronald F. Barron _14.WATER ZONES - '
Well Contractor Name FROM TO DESCRIPTION
ft. ft. I I
2091-A ft. ft.
NC Well Contractor Certification Number .15.OUTER CASING.(for multi-cased'wells)OR LINER(if ap licable)
Piedmont Industrial Services FROM TO DIAMETER, - THICKNESS 1 MATERIAL
ft. ft. I, in.
Company Name
2024-28-06-M W 13-RWO .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.) 0 ft. 20 it 2 I. ill Sch 40 we
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 47.SCREEN 1` " .
FROM TO DIAMETER' 'SLOT SIZE THICKNESS MATERIAL
al Agricultural 0Municipal/Public 20 ft 35 ft 2 in' .010 Sch 40 PVC
*Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft - ft. • i
•i lndustrial/Commercial E3Residential Water Supply(shared) 18.GROUT.
I Irri•ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 16 it Concrete' Poured
MI Monitoring EDRecovery 16 ft 18 ft Bentonite Poured
- Injection Well: _ -
ft ft.
rig,Aquifer Recharge 0Groundwater Remediation .
19.SAND/GRAVEL PACK'(if'applicable)
all Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD .
III Aquifer Test ]Stormwater Drainage 16 ft 35 ft .#3 well sand Poured
Experimental Technology 1'__f Subsidence Control ft. ft.
SI Geothermal(Closed Loop) OTracer 20.'DRILLING LOG(attach additional sheets if necessary) = - . .. .
C�Geothermal(Heating/Cooling Return) *Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,Brain size,etc.)
0 ft 10 ft. Red Clayey silt
4.Date Well(s)Completed:8-28-24 Well ED#MW-4 10 ft 15 ft Tan Brn Silty sand
5a.Well Location: 16 ft. 35 ft Tan Brn PWR
Universal Industrial Park, LLC N/A ft. ft BT @ 35 '',it°•_:, w,
Facility/Owner Name Facility ID#(if applicable) ft. ft. i' ' r Li
2411 E. Martin Luther Jr. King Drive, High Point 27260 ft. ft. SEP 2 0 � n
Physical Address,City,and Zip ft. ft
Guilford N/A 21.REMARKS _=_ cv,,-• s d. ` 1!s:a�
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 57.9240 N 79 57.7450 W
,,e,...,.a. ---- -1zr_.. --. 9-13-24
6.Is(are)the well(s) Ix...Permanent or Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or iX No with 15A 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#21 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:wA SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 35 (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: I
10.Static water level below top of casing:24.24 (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: 1 0 (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.) 1
i
Division of Water Resources,'Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service i enter,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 subtititl 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-1 North Carolina Department of Environmental Quality-Division of Water Resources s Revised 2-22-2016