GW1-2022-07812_Well Construction - GW1_20220819

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple Hells
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 THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 10 ft. in. sch40 PVC
List all applicable well permits(i.e.Couniv.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 10 ft' 20 fir- 2 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 1 10 ft. Portland Cem Tremie
Non-Water Supply Well:
10 ft. 16 fr. Bentohite Chi Tremie
(7JMonitoring ❑Recovery
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PAC K if 5 licable
.,❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 16 ft- 20 ft- #1 Sand I Tremie
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG sttach,additionial sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type.grain siu,etc.
❑Geothermal(Heating/Cooling Rewm) ❑Other(explain under 421 Remarks) ft. ft.
ft. ft. 4 u -,�
4.Date Well(s)Completed: 6-22-22 Well ID# MW-10 w
ft. ft.
5a.Well Location: ft. ft. Alh ! 9 lRy-
Lanxess Corporation ft. ft.
Facility/Owner Name Facility ID#(if applicable) � -
R. ft. :31 aQ/30G
520 Broome Road, Greensboro 27604 ft. ft.
Physical Address,City,and Zip -
21.REMARKS
Guilford as 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) -
36.038750 N -79.777708 W _ -:7, a-
Signature of Certified Well Contractor Date
6.Is(are)the well(s): [OPermanent or ❑Temporary By signing dtis form, I hereby certify that the ire/l(s) was(here)constructed in accordance
with 15A 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 olthis record has been provided to the hell owner.
If this is a repair,fill out known well construction iglbrmation and explain the nature of the
repair under=21 remarks section or on the back of'dtix 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.
liar muhiple injection or non-water.supply hells 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
For multiple wells list all depths if'dtff&rent(example-3 a 200'and 2@100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
4 water level is above casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2 (in.) 24b. For Infection Wells ONLY:'I In addition to sending the form to the address in
24a above, also submit a copy ofthis 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 forib within 30 days ofcompletion 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 NattuA Resources-Division of Water Resources Revised.August 2013