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WELL CONSTRUCTION RECORD For Internal Use ONLY: '
This form can be used for single or multiple wells
I.Well Contractor Information:
Virgil Wilson 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 20 ft. 75 ft. I Wet
4473 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. o ft. 58 ft. 4 in' sch40 pvc
Company Name 16.INNER CASING OR`TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 65 ft. 2 in. sch40 pvc
List all applicable well permits(i.e.Coun(v,State, Variance,/njection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN ' ;'
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 65 ft. 75 f` 2 in. .010 sch40 pvc
ft. R. in.(Heating/Cooling Supply) ❑Residential Water Supply(sin le)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 1.5 ft• 60 ft. Portland Cem Tremie
Non-Water Supply Well:
ElMoni[oring DRecovery 60 ft. 63 ft. Bentonite Chi Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stonnwater Drainage 63 ft• 75 ft• #1 Sand Tremie
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/ruck type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) ft. ft.
ft. fr.
4.Date Well(s)Completed: 2-10-22 Well lD# MW-12D
ft. ft. I
5a.Well location: '
Speedway, LLC 6952 ft. ft. MAR 1 707�
Facility/Owner Name Facility ID4(if applicable) ft. ft.
2201 N. Main Street, High Point 27262 ft. ft.
Physical Address,City,and Zip
21.REMARKS ,
Guilford 0194670
County Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one fat/long is sufficient)
35.984053 N -80.023996 w ( Y'"
matureCertifWeII Contra Date
6.Is(are)the well(s): ❑Permanent or ❑Temporary By signing this farm l hereby certi(v that the we/l(s)was(were)constructed in accordance
with 15A N('AC 02('.0100 or ISA NI'A('02('.0200 Well I'mistruction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo cope of this record has been provided to the well owner.
kilns is a repair,fill out known well construction infbrnmtion and explain the stature oldie
repair under,r21 remarks section or on the back of this farm. 23.Site diagram or additional well details:
You may use the back of this page Ito provide additional well site details or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or nun-water.supply wells ONLY with the name construction,yots can
submit onePrnt. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 75 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
I•or multiple wells list all depths if different(example-3@200'and 2 rt l00) construction to the following:
I
10.Static water level below top of casing: 20 (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 1 11/4" (in.) 24b. For Injection Wells ONLY: Iln addition to sending the form to the address in
6 5/8 HSA / 4" Air Rotary 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.) t
Division of Water Resources,(Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
(gpm)
24c.For Water Supply&Injection Wells:
m 13a.Yield Method of test:
Also submit one copy of this form Within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
Form G W-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013