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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells i,
I.Well Contractor Information:
Virgil Wilson 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 20 ft. 26 ft. I VVet
4473 ft. ft. I
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap 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. 16 ft. 2 in. sch40 pvc
List all applicable well permits(i.e.('onn(v.,Sale,Variance,Injection.etc.)
ft. ft. in.
3.Well Use(check well use): •17.:SCREEN i`
Water Supply Well: FROM TO DIAMETER ' SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 16 ft. 26 O. 2 in' .010 sch40 pvc
ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(sin le)❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 1.5 ft. 12 ft• Portland Cem Tremie
Non-Water Supply Well:
fJMonitoring ❑Recovery 12 ft. 14 ft. Bentonite Chi Tremie
Injection\%ell: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 14 ft' 30 ft. #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLINGLOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,suil/ruck type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
2-9-22 MW-15 Et. ft. •
4.Date Well(s)Completed: Well ID# ft. ft.
Sa.Well Location: ft. ft. f.:i. i
Speedway, LLC 6952 ft. ft. t
Facility/Owner Name Facility IDS(if applicable)
ft. ft. MAR1 4 2027
2201 N. Main Street, High Point 27262 ft. ft.
Physical Address,City,and Zip
21.REMARKS t -
Guilford 0194670
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)
35.984114 N -80.024013 wipiu_z.4a•,,)a .?a-
Signature o .etlitied Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary Hy signing this fort, l hereby ceriifi'that the well(s)was(were)constructed in accordance
with/SA N('A('02C.0100 or 15A NCAC 02C.02011 Well('cnt.rtruction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy ofthis record has been provided to the well owner.
If this is a repair,fill out known well construction infitrmaiioit and explain the nature of the
repair under all remarks.section or on the back of'this 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.supple wells ONLY with the saute construction,pm can
submit one jarm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 26 (ft.) 24a. For All Wells: Submit this,form within 30 days of completion of well
For multiple wells list all depths if dif/kreni(example-3@200'and 2@/00') construction to the following:
I
10.Static water level below top of casing: 20 _ (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: 8 (in.) 24b. For Injection Wells ONLY: In addition to sending the form to the address in
4 1/4 HSA 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.auger,rotary,cable,direct push,etc.) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
24c.For Water Supply&Injection Wells:
I3a.Yield(gpm) Method of test:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county hea4lth department of the county where
constructed. V
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Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013