GW1-2022-07813_Well Construction - GW1_20220819

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WELL CONSTRUCTION RECORD For Internal Use ONLY: I
This form can be used for single or multiple wells i
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1.Well Contractor Information:
14.Todd Muench FROM WATER Z ONES DESCRIPTION
Well Contractor Name ft.
3371 ft. e.
1 ,
NC Well Contractor Certification Number 15.OUTER CASING for multi-casedwells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 10 ft. in• sch40 PVC
List all applicable well permits(i.e.County.State, Variance,Injection,etc.)
ft. ft. in.
3.Well Ilse(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 10 ft' 20 ft- 2 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 10 ft- Portland Cem Tremie
Non-Water Supply Well:
10 r` 16 rr• Bentonite Chi Tremie
❑Monitoring ❑Recovers
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ifa licible
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑ f-Salinity Barrier
16 20 ft. #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock e, rain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
4.Date Well 6-22-22 s)Completed: Well ID# MW-2R f`• ft.
ft. ft.
5a.Well Location: ft. ft.
Lanxess Corporation ft. ft. „
h ro..e1 t 5 Y/
Facility/Owner Name Facility IDti(ifapplicable) ft. ft.
520 Broome Road, Greensboro 27604 ft. ft. Ali 202?
Physical Address,City,and Zip 21.REMARKS infermaAjeiq
Guilford ' ',"O
Flush mount J'at"r'�
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field one lat/long is sufficient)
36.039655 N -79.777943 w�
Signature oftertified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary RV signing this form,I herebv certify that the we/l(s)was(here)constnicied in accordance
With 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy o/this record has been provided io the well owner.
1f this is a repair,Jill out known well construction information and explain the nature of the
repair under=21 remarks section or on the back of'1his.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 of wells constructed: 1 construction details. You may alsojattach additional pages if necessary.
For multiple injection or non-waler supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 20 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijjereni(example-3@200'and 2@100') construction t0 the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
1J water level is above casing,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2 (in.) 24b. For Infection Wells ONLV:II 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: construction to the following: i
(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&Injection Wells:
(gP ) 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