GW1-2022-07809_Well Construction - GW1_20220819

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Todd MUench 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
3371 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
FROM TO DIAMETER' THICKNESSI MATERIAL
Parratt-Wolff, Inc. ft. ft.
Company Name 16.INNER CASING OR TUBING eothermal closed-loo
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 8 ft. in. seh40 PVC
List all applicable well permits(i.e.Counw.Slate,Variance,Inieclion,etc.)
f[. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public g fr. 18 ft. 2 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. fr. in.
❑Industrial/Commercial ❑Residential Water Supplv(shared) IS.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation Non-Water Supply Well: 0 e. 10 B. Portland Cem Tremie
oMonitoring ❑Recovery 10 ft- 16 ft- Bentonite Chii Tremie
Injection Well: fr. R.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a liea6le
FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 16 tr. 18 fr. #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additionatsheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color.hardness,soil/rock type,gmin sit,etc.
❑Geothermal(Heating/Cooling Rewm) ❑Other(explain under#21 Remarks) fr. ft.
ft. ft. �. X '' d G
4.Date Well(s)Completed: 6-23-22 Well ID# MW-14
ri
ft. ft.
5a.Well Location: fr. ft. ! _
Lanxess Corporation ft. fr.
Facility/Owner Name Facility lD#(if applicable) ft. ft. Ri?;' 't
11.l�.�520 Broome Road, Greensboro 27604 ft. ft.
Physical Address,City,and Zip
Guilford 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one[at/long is sufficient) �C
36.038423 N -79.776562 W �'D ��-� �k� a a
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary
Hv signing this farm, 1 hereby terrify that the we//(.c)was(were)constructed in accordance
with I SA 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 ONo copy o/ihis record has been provided to the we//owner.
If this is a repair,Jill out known it-ell construction information and explain the nature of the
repair under,21 rentarkv section or on the hack of this trm, 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 ofwells constructed: 1 construction details. You may also attach additional pages ifnecessarv.
For multiple injection or non-water supply wells ONLY irid;the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 18 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdgferem(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,
If,rater/ere/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
24a above. also submit a copy of this form within 30 days of completion of well
12.Well construction method: F ISA 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 Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply&InjectionWells:
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. i
Form GW-I North Carolina Department of Environnient and Natural Resources-Division of Water Resources Revised August 2013