GW1-2022-05810_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
ft. ft.
4343 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. I in.
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
FROM TO DIAMETER THICKNESS I MATERIAL
2.Well Construction Permit#: 0 ft. 55 ft. in. SCh40 PVC
List all applicable well permits(i.e.County,State, Variance,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 55 ft- 65 ft. 2 t"• .010 SCh40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 rt. 48 ft. Portland Cem Tremie
Non-Water Supply Well:
❑O Monitoring ❑Recovery
48 ft. 53 ft. Bentonite Chii Tremie
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 1.9.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
rt• rt•
❑Aquifer Test ❑Stormwa[er Drainage 53 65 #1 Sand Tremieft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach addifid'oal sheets if necessary)
❑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. R.
4.Date Well 5-24-22 MW-101 s)Completed: Well ID#
5a.Well Location:
Southern Railway Co Southern Railway Yard ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
3303 Spring Garden St, Greensboro 27407 ft. ft.
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)
36.058392 N -79.846573 W t.�SC .cp-zZ
Signature of Certified=Yv
tor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary Hv signing this1brnt, that the well(v)wa./were constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Co , Ilion Standards and that a
7.Is this a repair to an existing well: ❑Yes or ❑No cony q/this record has been provided to the well owner.
1/this is a repair,Jill out known well construction iglbrmation and explain the nature ofthe
repair under:=21 remarks section or on the back of this.lornt. 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 nmlliple injection or non-water supp(v wells ONLY with the same conslracdon,vnu can
submit one,/ornt. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 65 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
hor nnuhiple wells list all depths Y*dt%jerent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
I/'water level is above casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 2 (in.) 24b. For Infection Wells ONLY:' In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Sonic 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:
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.
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Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013