GW1-2022-03091_Well Construction - GW1_20220307

WELL CONSTRUCTION RECORD For Internal use ONLY:
This form can be used for single or multiple wells 1
I.Well Contractor Information:
14.WATERZONES
Virgil Wilson
FROM TO DESCRIPTION
Well Contractor Name 20 ft' 26 ft• Wet
4473 ft. ft. i.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a Bcable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. rt. ft. in,
Company Name 16.INNER CASING OR TUBING geothermal closed-lod
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. 2
0 16 in. SCh40 pvc
List all applicable well permits(i.e.C'otoov,State,Variance,bryeetion,etc.)
ft. ft. in.
I
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 16 r" 26 ft• 2 '"' .010 SCh40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. ini
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT c
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 1 5 ft• 12 ft• Portland Cem Tremie
Non-Water Supply Well:
ry 12 ft- 14 ft- Bentonite Chi Tremie
@Monitoring ❑Recove
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if a- ►ieable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
14 ft• 30 ft. #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLtNGLOG attach addition"al!sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Rewm) ❑Other(explain under#21 Remarks) ft. ft.
4.Date Well 2-9-22 s)Completed: Well ID# MW-15 ft. ft.
ft. ft.
5a.Well Location:
Speedway, LLC 6952 ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) u
ft. ft. f\ 2022
2201 N. Main Street, High Point 27262
Physical Address,City,and Zip a 21.REMARKS }..
Guilford 0194670 ,lads' fl;:41 PAIXIE 31I 1
County Parcel identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Cr ca on:
(ifwell field.one lat/long is sufficient)
35.984114 N -80.024013 W
Signature ofTa
fie ell Contractor Date
6.Is(are)the well(s): Permanent or ❑Temporary Hv signing d . rit, I herebv tern&that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or I5A NCAC 02C.0200 Well Consirucliat Standards and iha[a
7.Is this a repair to an existing well: ❑Yes or E]No copy olihis record has been provided to the well corner.
IJ'this is a repair,Jill our known well construction inlormaiion and explain the nature ofthe
repair under-21 remarks section or on the back gl'this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number ofwells constructed: 1 construction details. You may also attach additional pages ifnecessary.
For nnduple injection or non-water supply wells ONLY with the same construction,i it car
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 26 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple weN.s list all depths il_diJJereni(example-3 a 100'and 2@a 100') construction to the following:
10.Static water level below top of casing: 20 Division of Water Resources,Information Processing Unit,
(/'water level is above casing,use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2 (in.) 24b. For Infection Wells ONLY: In addition to sending the form to the address in
4 1/4 HSA spoons 24a above, also submit a 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 Resourck Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service(enter,Raleigh,NC 27699-1636
13a.Yield m Method of test: 24c.For Water Supply&Injection Wells:
(gP ) Also submit one copy of this form lwithin 30 days of completion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed. I '
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013