GW1-2022-03090_Well Construction - GW1_20220307

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WELL CONSTRUCTION RECORD For Internal Use ONLY: I
This form can be used for single or multiple wells
I.Well Contractor Information: 1
14.WATERZONES
Virgil Wilson
FROM TO DESCRIPTION
Well Contractor Name 20 ft. 75 rr. f Wet
4473 rt. ft. i
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS I MATERIAL
Parratt-Wolff, Inc. 0 ft. 58 ft 4 ! in. 1 SCh40 I PVC
Company Name 16.INNER CASING OR TUBING 'eothermal closed-loo
FROM TO I DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 65 ft. 2 in- SCh40 PVC
list all applicable well permits(i.e.C'ounty.State,Variance,lnjec•lion,elc.)
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 ft- 2 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supplv(single) ft. ft. in.
❑Industrial/Com mere ial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 1.5 ft. 60 ft Portland Cem Tremie
Non-Water Supply Well:
zMonitorinia ❑Recovery
60 ft 63 ft. Bentonite Chi Tremie
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if a livable _
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 63 ft' 75 ft- #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG tattachfadditionalisheets ifn&emi
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION color,hardness,soillmck type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) ft. ft.
ft. ft.
4.Date Well(s)Completed: 2-10-22 well ID# MW-12D
ft. ft.
5a.Well Location: R. ft.
Speedway, LLC 6952 ft. ID
ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
2201 N. Main Street, High Point 27262 f. ft.
Physical Address,City,and Zip 21.REMARKS ti'r
Guilford 0194670 =at Y. I
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)
35.984053 N -80.023996 W. IiA
.��.
Sig drure ofC tifie Well Contractor - Date
6.Is(are)the well(s): ©Permanent or ❑Temporary gv signing this Jorm,1 herebv certify that the well(s)was(were)constructed in accordance
frith I5A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy of this record has been prorided to the well owner.
/f this is a repair,fill out known well construction information and explain the nature of the
repair under-21 remarks section or on the back of lhis,forn,, 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details of well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
/or multiple injection or non-water.supply wells ONLY with the same construction,you can
submit one Jorm. 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
For muhiple wells list all depihs ifdt/ferent(example-3 a 200'and 2@100') construction to the following:
10.Static water level below top of casing: 20 (ft.) Division of Water Resources,Information Processing Unit,
!/baterlerel is above casing,use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
I I.Borehole diameter: 2 (in.) 24b. For Injection Wells ONLY:! In addition to sending the form to the address in
4 1/4 HSA spoons 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(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.
Form GW-I North Carolina Department of Enviromnent and Natural Resources-Division of Water Resources Revised August 2013
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