GW1-2022-05813_Well Construction - GW1_20220609

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
Anthony Convery FR WATER ZONES I
FROM TO DESCRIPTION
Well Contractor Name ft. ft. 6
4343
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER if a livable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft_
j in.
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 f`' 110 f`' '"' SCh40 PVC
List all applicable well permits(i.e.County,Stare, 1,oriance,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 110 f`' 120 f`' 2 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft' f`' in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 f` 100 ft- Portland Cem Tremie
Non-Water Supply WeII:
100 ft• 107 ft Bentonite Chi Tremie
❑�Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
107 ft• 120 f`• #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) []Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
4.Date Well 5-27-22 MW-11 Ds)Completed: Well 1D#
5a.Well Location: ft. ft.
Southern Railway Co Southern Railway Yard `� ''Alp
Facility/Owner Name Facility ID#(if applicable)
3303 Spring Garden St, Greensboro 27407 ft. ft.
Physical Address.City,and Zip 21.REMARKS
Guilford 7854316985 nlfoipll Cn ' 'ng nrt
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)
36.057924 N -79.848399 �;
Signature of Certified We Contractor: Date
6.Is(are)the well(s): Permanent or ❑Temporary By signing this.jorm, I here y certi&that ih was(were)consvntcved in accordance
with 15A NCAC 02C.0l00 or I5A NCAC 02C.0200 Well Constntction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy o('this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature q/lhe
repair under=2I remarks section or on the hack o/this./orm. 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 oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 120 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
I•or multiple wells list all depth 4 di#ereni(example-3@200 and 2@/00') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
ljwater 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
Sonic 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following: gg
(i.e.auger,rotary,cable.direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail ServiceCenter,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply Wells:&Infection
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county 1health 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