GW1-2022-07705_Well Construction - GW1_20220811

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
L Well Contractor Information:
Todd Muench 14.WATER ZONES 4
FROM TO DESCRIPTION
Well Contractor Name ® ft. '($ -�ft. 1. �r•tiL
3371 ft. ft.
NC Well Contractor Certification Number CCEq 15.OUTER CASING for multi-cased wells OR LINER if a licable
5�VEDFROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. 4 ft. ft. I in.
Company Name t 16.INNER CASING OR TUBING(geothermal elosed-loo
A.IJG ! 2022 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft' 152.2 ft. 2 i" SCh40 pvC
iv all applicable well permits(i.e.Countyy Slalt(,f{ajylrItpp{"QjM1RV--T3"14*
ft. ft. in.
3.Well Use(check well use): D'NUSOG
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 152.2f"- 162.2 ft. 2 1n .010 sch40 PVC
❑Geothermal(Heating/Cooling Coolin Supply) ❑Residential Water Su ly sin le ft. ft. in.
( g PP Y PP ( g )
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 2 ft. 55 ft- Bentonite Chil Tremie
Non-Water Supply Well:
' 55 ft- 143 f`. Portland Cem Tremie
IZJMonitoring ❑Recoven
Injection Well: 143 ft- 148 ft. Bentonite Tremie
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑salinity Barrier 148 62.5 ft. #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage ft. 1
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)'
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color•hardness,soil/mck type,grain size,etc.
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) 0 rt. 5 It. Concrete,gravel,grey moist clay and sand
4.Date Well(s)Completed:
7-26-22 Well ID# MW-17 5 ft 10 ft. I Grey moist clan
10 fr• 15 fr• Grey moist cland and sand trace,brown san
5a.Well Location:
15 fr• 20 ft. Grey,moist clay with dense sand and silt
Chemcentral Atlantic Corp Univar Facility 20 fr• 162.5 ft-
Blue gray rock
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
108 Oakdale Road, Jamestown 27282
ft. ft.
Physical Address,City,and Zip 21.REMARKS
Guilford 7821374461 2 x 2 Square Pad
County Parcel Identification No.(PIN) 8„FMC
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field one[at/long is sufficient)
35.992050 N -79.935545 W "<6-11n) N, • ZZ._
Signature ofCertitied Well ontracton. Date
6.Is(are)the well(5): Permanent or ❑Temporary By signing dus/orm, I hereby certifvithal the it ell( was(were)constructed in accordance
with 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy oJ7his record has been provided to the well owner.
If'Ihis is a repair,Jill out known well construction information and explain the nature ofthe
repair under=21 remarks section or on the hack q(this Joan. 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 muhiple injection or non-trater.supirN wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 162.5 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple hells list all depths tfdtfferem(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 28•5 (ft,) Division of Water Resources,Information Processing Unit,
I)uvaler level is above casing,use" 1617 Mail Service'Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b. For Injection Wells ONLY: In addition to sending the form to the address in
8 1/4 - 6" casing 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,eta)
Division of Water Resourcl s,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
m 13a.Yield
(gp ) 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
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