GW1-2022-05812_Well Construction - GW1_20220609

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Anthony Convery 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
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 closed4mi
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 55 ft. in. SCh40 PVC
List all applicable well permits(i.e.C'nuniv.State, D•artance,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 55 ft' 65 rc• 2 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) f. ,in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 47 ft. Portland Cem Tremie
Non-Water Supply Well:
❑OMonitoring ❑Recovery 47 rt• 53 ft- Bentonite Chi Tremie
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ifapplicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 53 rr• 65 rc• #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 type,gnin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) ft. ft.
ft. ft.
4.Date Well 5-27-22 MW-111 s)Completed: Well ID# ft. ft.
5a.Well Location:
Southern Railway Co Southern Railway Yard R:.. `
Facility/Owner Name Facility ID#(if applicable) ft. ft. I I I hl
019.2027
3303 Spring Garden St, Greensboro 27407 rt. rL J V IV
Physical Address;City.and Zip 21.REMARKS Intui t^'
Guilford 7854316985
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)
36.057924 N -79.848399. N; N-s - Z
Signature of Certified Well Contr or Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form, I hereby cc ' ,that the well(.,) was onstr ucled 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 END copy of lhis record has been provided to the well owner.
IJ'this is a repair,Jill nut/mown well construction iglbrtnation and explain the nature gjthe
repair under=21 remarks section or on the back of fhisjorm. 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 supply wells ONL Y with the same construction,you can
submit onefnrm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 65 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
/•br multiple we/Ls list all depths tJ'diJJereni(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,
1fwater 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
Soule 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.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service'enter,Raleigh,NC 27699-1636
i
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 Environment and Natural Resources-Division of Water,Resources Revised August 2013