GW1-2022-07811_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 Haunch 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 ticable
FROM TO. DIAMETER I THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. o"•
Company Name 16.INNER CASING OR TUBING eothermal closed-loop
FROM I TO DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit#: 0 fr. 10 ft. I i" SCh40 I PVC
List all applicable hell permits(.i.e.County,State, Variance,Injection,etc.)
ft. I ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER. SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 10 "' 20 ft' 2 in. .010 SCh40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irri ation 0 1. 10 ft- Portland Cem Tremie
Non-Water Supply Well:
10 ft. 16 a. Bentonite Chil Tremie
OMonitoring ❑Recoven
Injection Well:
ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACKifa`licahle
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 16 ft' 20 ft- #1 Sand Tremie
ft. fr.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG atta h:additionid sheets:if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color•hardness,soiUmck type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) I ft. fr.
4.Date Well(s)Completed: 6-22-22 Well ID# MW-12 ft. ft.
y ,w r1
ft. ft.
5a.Well Location: ft. ft.
AO_, 1 9 z@22
Lanxess Corporation ft. ft.
Facility/Owner Name Facility ID#(ifapplicable)
ft.
520 Broome Road, Greensboro 27604 ft.
ft. ft.
Physical Address,City,and Zip
21.'REMARKS
Guilford 4"Stick up
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)
36.038691 N -79.776883 W. i� `� -7. lZ5'2-;-;,
Qnature of Certified Well Contractor Date
6.Is(are)the well(s): Permanent or ❑Temporary By signing this form,I hereby certily that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or I5A NCAC:02C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy ofihis record has been provided to the shell owner.
Ii'this is a repair,Jill out known well construction inlormation and explain the nature oJ7he
repair under--21 remarks section or on the back of'dris form. 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-seater supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 20 24a. For All Wells: Submit this;form within 30 days of completion of well
hor multiple wells list all depths it di)Jereni(example-3 tt 200'and 2@100') construction t0 the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
tfwater level is above casing,use " 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2 (in.) 24b. For Inicction Wells ONLY: In addition to sending the form to the address in
24aabove, 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
m 13a.Yield
(gP ) Method of test: 24c.For Water Supply&InjectioniWells:
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