GW1-2022-05811_Well Construction - GW1_20220609

WELL CONSTRUCTION RECORD For Internal Use ONLY.
This form can be used for single or multiple wells
I
1.Well Contractor Information:
ConVe 14.WATER ZONES
Anthony
rY FROM TO DESCRIPTION
Well Contractor Name ft. ft-
4343
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. ( in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft' 72 ft. i" SCh40 PVC
List all applicable well permits(i.e.Couniv.Slate. 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 72 It- 82 ft- 2 in. .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 f" 64 ft- Portland Cem Tremie
Non-Water Supply Well:
❑�Monitoring ❑Recovery
64 rt• 69 rt• Bentonite Chi Tremie
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK'if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery []Salinity Barrier 69 e' 82 rr• #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage R. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional 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 421 Remarks)
ft. ft.
4.Date Well(s)Completed: 5-24-22 Well ID# MW-10D ,e
ft. ft. .�•� E
5a.Well Location:
Southern Railway Co Southern Railway Yard rt rt �ZZ
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Infof�i�;icn Pr cIP zi.,
3303 Spring Garden St, Greensboro 27407 e ft Jic*1Q18(K
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[at/long is sufficient)
36.058392 N -79.846573 w C9 , 2Z
Signature of Certified Well Co actor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this%rm, 1 hereby certify that the we as(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or FINo copy gl'Ihis record has been provided to the well owner.
Ifthis is a repair fill out known well construction in/onnalion and erplain the nature gflhe
repair under 21 remarks section or on the hack gf this 1brm. 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.
Far mulliple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 82 24a. For All Wells: Submit this form within 30 days of completion of well
h'or multiple wells list all depths tfdVArent(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,
t/'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 iof 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 m Method of test: 24c.For Water Supply&Inicchon Wells:
(gp ) Also submit one copy of this form within 30 days of completion of
13b.Disinfection type Amount well construction to the countyl health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013