GW1--04859_Well Construction - GW1_20230728

WELL CONSTRUCTION RECORD For internal Use ONLY:
This form can be used for single or multiple wells I
1.Well Contractor Information: - -
Gary Ellingworth 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 46 f`• 55 f`• wet
3367 ft. ft.
NC Well Contractor Certification Number15.OUTER CASING(for multi-cased wells)OR LiNER(if ap licable)
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft, ft• in,
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2021-03-15-15-MW26-RW48 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft* 40 ft• 2 in' sch40 pvc
List all applicable well permits(i.e.County.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 40 f`' 55 ft, 2 '"' .010 sch40 pVC •
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) iS•GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 ft• 34.5 Portland Cem Tremie
Non-Water Supply Well:
❑o Monitoring ❑Recovery 34.5 ft• 37.5 ft- Bentonite Chil Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
37.5 ft. 55 ft. #2 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary).
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soiUrock type,grain sire,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
ft. ft.
4.Date Well(s)Completed: 06-07-23 Well iD#2W 31 ft. ft. - 7` r- r*'"h
t L'La 1 i V r"iJ
5a.Well Location: ft. ft.
Plantation Pipe Line Company 3571 ft. ft. JUL 2 o t02�
Facility/Owner Name Facility ID#(if applicable) ft. ft.
)nfGi ir.`4i 1 r r ..�•••�,��
:440:g Ufa
2701 Quaker Landing Road, Greensboro 27455 ft. ft. CNA). LX
Physical Address.City.and Zip 21.REMARKS
Guilford 7847837248 S"Flush Mount Cover
County Parcel identification No.(PiN) 2'Concrete Pad
5b.Latitude and Longitude in degrees/minutes/seconds or,decimal degrees: 22.C ti cation:
(if well field,one lat/long is sufficient)
36.147008 N -79.850614 W (°Z,e Z3
Signature i f Certified We on actor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By sigm» his form,i here y ertify that the well(s)w'ns(were)constructed in accordance
with 15,4 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 of this record has been provided to the well owner.
If this is a repair.fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this 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-water supply wells ONLY with die same construction.you can
submit one form. " SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 55 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'200'and 2@l00') construction to the following:
10.Static water level below top of casing: 46.20 - (ft,) Division of Water Resources,information Processing Unit,
!flirter level is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8•75 (in.) 24b. For Injection Wells ONLY: In addition to sending the form to the address in
Air Rotary 24a above, also submit a copy of this form within 30 days of completion of well
Hollow Stem Auger,
12.Well construction method: 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 m Method of test: 24c.For Water Supply&Injection Wells:
(gp ) 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 201 3