GW1-2022-07810_Well Construction - GW1_20220819

'{ I
WELL CONSTRUCTION RECORD For Internal Use ONLY: Y!
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. fr.
3371 ft. ft.
i
NC Well Contractor Certification Number 15.OUTER CASING for multi-eased OR LINER if a 7icable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. f in.
Company Name 16.INNER CASING OR TUBING geothermal closed-loop)
FROM I TO DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft' 5 ft• i" SCh40 PVC
List all applicable well permits(i.e.Coun(v,State,Variance.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 5 ft. 15 ft. 2 i"•' .010 sch40 PVC
ft. ft. in.'❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) �o ROUT To MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 10 ft, Portland Cem Tremie
Non-Water Supply Well:
10 ft- 12 ft Bentonite Chi Tremie
Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if.a licable
FROM TO MATERIAL EMPLACEMENT METHOD '
❑Aquifer Storage and Recovery ❑Salinity Barrier12 tt' 15 ft. #1'Sand Tremie
El Aquifer Test ❑StormwaterDrainage ft. ft
❑Experimental Technology ❑Subsidence Control
20.]DRILLING I OG attach additimud 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) ft. ft. 4: ��
6-23-22 MW-13 ft. fr. w� �. e _f E
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location: ft. ft.
Lanxess Corporation ft. ft. Iftlr%rigi:&a%+1g UR i
Facility/Owner Name Facility ID4(ifapplicable) ,
ft. fr.
520 Broome Road, Greensboro 27604 ft. ft.
Physical Address,City,and Zip
21.REMARKS
Guilford
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field.one ladlong is sufficient)
36.038677 N -79.776758 W� - (S a a
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary
By signing this Jorm, 1 hereby certify that the+vell(s)was(mere)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.
1l this is a repair,Jill out known well construction in/brmation and explain the nature ol7he
repair under=21 remarks.section or on the back gf1his Jorm. 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 ONLY with the same construction,you can
submit one Jorm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 15 (ft.) 24a. For All Wells: Submit this!form within 30 days of completion of well
For multiple wells/is/all depths ifdilfereni(example-3 rr 200'and 2@100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
ry'mater 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
24a above, also submit a copy of this form Within 30 days of completion of well
12.Well construction method: HSA 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&Injection,Wells:
Also submit one copy of this form within 30 days ofcompletion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed. 6
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013