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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information: v
Virgil Wilson 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 20 ft' 26 ft. I Wet
4473 ft. ft. I
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap livable)
FROM TO DIAMETER I THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. i in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit 14: 0 ft• 16 ft. 2 in* sch40 pvc
List all applicable well permits(i.e.County.State.Variance,Infection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN is
Water Supply Well: FROM TO - DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 16 ft. 26 e• 2 i"'' .010 sch40 pvc
ft. ft. in.❑Geothermal(Heating/Cooling Supply) DResidential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18,GROUT l:
FROM TO MATERIAL EMPLACEMENT METHOD_&AMOUNT
❑Irrigation 0 ft. 11 ft* Portland Cem Tremie
Non-Water Supply Well: -
11 ft• 14 ft' Bentonite Chii Tremie
OMonitoring ❑Recovery
Injection Well: ft. ft.
DAquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
DAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test ❑Stormwater Drainage 14 ft. 26 ft- #1 Sand Tremie
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(calm,hardness,suit/ruck type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
ft. ft.
4.Date Well(s)Completed: 2-9-22 Well ID# MW-16 ft. ft. .
5a.Well location: ft. ft. •
Speedway, LLC 6952 r-- — -- T,
P Y' ft. ft. - )-. ,
Facility/Owner Name Facility IDk(if applicable)
ft. ft.
2201 N. Main Street, High Point 27262 ft. ft. MAR 1 I M9 9
Physical Address,City,and Zip
21.REMARKS •
Guilford 0194670
County Parcel Identification No.(PIN) "`""'.'' t'•=. ,;;I
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22, ertification:
(if well field,one lat/long is sufficient) F
35.984157 N -80.023720 N, V G p (y 9 0)•a2- Zz
Signature of ei 'ied Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary f /Y U (were)Hy signingthis Prot, I hereby c•erti that the wells was were constructed in accordance
with I5A N('A('02( .01011 or 15A N('AC 02('.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or IL No copy of this record has been provided to the well owner.
If this is a repair,fill owl known well construction in/urination and explain the nature(Ow
repair tinder c21 remarks section or on the hack of this/brm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple infection or non-water.supple wells ONLY with the some construction,l'nu 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 mallip/e wells list all depths if different(example-3@2110'and 2@l00') construction to the following:
10.Static water level below top of casing: 20 (ft.) Division of Water Resources,Information Processing Unit,
If'water level is shore casing,use"." 1617 Mail Service Center,Raleigh,NC 27699-1617
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II.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 tollowing:
(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
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13a.Yield m Method of test: 24c.For Water Supply&Injection Wells:
(gP ) Also submit one copy of this fortis 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 Environment and Natural Resources—Division of Water Resources Revised August 2013