GW1--05697_Well Construction - GW1_20240920

1
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: j
1.Well Contractor Information: I
I
Ronald F. Barron la:wATERZONEs.
FROM TO DESCRIPTION
Well Contractor Name
ft ft.
2091-A ft ft '
NC Well Contractor Certification Number 15:OUTER CASING(formulti-cased'wells)OR LINER(if ap licable)
Piedmont Industrial Services FROM TO DIAMETER I THICKNESS 1 MATERIAL
ft. ft. 1 in.
Company Name 16.INNER'CASING:OR TUBING,(geothermel.closed-loop),
2.Well Construction Permit#:2024-28-06-MW 13-RWO FROM TO- DIAMETER` THICKNESS MATERIAL
List all applicable well construction permits(i.e.(1IC,County,State,Variance,etc.) 0 ft. 15 ft. 2 I. in. Sch 40 avc
3.Well Use(check well use): ft ft i in.
Water Supply Well: 17.SCREEN_ - '
FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
NI Agricultural 0Municipal/Public 15 ft' 30 ft 2 in', .010 Sch 40 PVC
i Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft ft in.i .
Ni Industrial/Commercial DResidential Water Supply(shared)
18.GROUT., .. :_.- - ,
I Irrigation FROM TO MATERIAL- EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 11 ft Concrete Poured
ill Monitoring ID Recovery 11 ft. 13 ft Bentonite Poured
Injection Well: - _
*Aquifer Recharge (_E. GroundwaterRemediation ft. ft
.19.'SAND/GRAVEL-PACK(if applicable)
NI Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Ni Aquifer Test E3 Stormwater Drainage 13 ft 30 ft #3 well sand Poured
IN Experimental Technology D Subsidence Control ft. ft 1,
III Geothermal(Closed Loop) 0 Tracer 20.DRILLING LOG(attach additii e'al sheets if necessary)..:. - --,- . -_. .
Geothermal(Heating/Cooling Return) fl Other(explain under#21 Remarks) FROM I TO DESCRIPTION(color,hardness son/rock type,grain size,etc.)
0 ft 5 ft Red Org clayey silt
4.Date Well(s)Completed:8-28-24 Well ID#MW-2 5 ft 15 ft Red Bm silty sandy clay
5a.Well Location: 15 ft 30 ft Bm tan PWR
Universal Industrial Park,LLC • N/A a ft ft. BT@sq. -^
"
S
Facility/Owner Name Facility ID#(if applicable) ft ft. i ,; y_ •1, E \_N, u 7
2411 E. Martin Luther Jr. King Drive, High Point 27260 ft. ft. I; �4-..,
4'_
Physical Address,City,and Zip ft. ft. �� 0 G U24
Guilford N/A :-21:REMARKS• "jr' ---...::_a .. . . . --. -
County Parcel Identification No.(PIN) e'��'_
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35 57.9180 79 57.7690 ,
N W , � C-` ld��— 9-13-24
6.Is(are)the well(s)(JX(Permanent or [(Temporary Signature of Certified Well Contractor I i Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or 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:NIA- SUBMITTAL INSTRUCTIONS'
9.Total well depth below land surface: 30 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdtfferenl(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing:20.77 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service enter,Raleigh,NC 27699-1617
11.Borehole diameter: 10 (in.) 24b.For Infection 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 subniit l 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 , Revised 2-22-2016