GW1-2022-05755_Well Construction - GW1_20220609

WELL CONSTRUCTION RECORD For Internal use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
Anthony ConVery 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
4343
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable
FROM TO JDIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. ! ` in.
Company Name 16.INNER CASING OR TUBING(eothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft- 50 ft. in. sch40 PVC
Lis/all applicable well permits(i.e.County.Slate, 6ariance.Injection,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 50 ft. 60 ft 2 i.n. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) f. ft. in.
❑Industrial/Commercial ❑Residential Water Supplv(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 rt. 44 ft. Portland Cem Tremie
Non-Water Supply Well:
17Monitoring ❑Recovery 44 ft. 48 ft. Bentonite Chii Tremie
Injection Well: ft. R.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 48 ft- 60 ft. #1 Sand Tremie
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attaih additional'sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
ft. ft.
4.Date Well(s)Completed. 5-28-22 Well ID# MW-12I
Ell
ft. ft.
5a.Well Location: ft. ft. L_%_o : V
Southern Railway Co Southern Railway Yard
Facility/Owner Name Facility ID#(if applicable) ft. ft.
3303 Spring Garden St, Greensboro 27407 ft ft �,r -� 7.; �Zz�n9 ut
Physical Address.City.and Zip
21.REMARKS
Guilford 7854316985
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
36.057665 N -79.849796 W (o y 2 Z
Signature of Certified II Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary HY signing this farm,I herehv certi/d that tlr ell(s) as(were)constricted in accordance
with 15A NCAC OX.0100 or 15A NCAC 02C.0 ell Consiniction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy of this record has been prnvided;to the well owner.
If this is a repair,Jill out known well consinnction infonnation and explain the nature aJ'the
repair under,,2/remarks section or on the back gf1his farm. 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 of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONL Y with the same construction,you car
sahmil oneJbrni. SUBMITTAL INSTUCTIONS''
9.Total well depth below land surface: 60 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For nuthiple wells list all depths ifdijfereni(example-3@200'and 2@/00') construction to the following:
10.Static water level below top of casing: (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: 2 (in.) 24b. For Infection Wells ONLY: In addition to sending the form to the address in
Sonic 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.anger,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:
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. I
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013