GW1--06423_Well Construction - GW1_20231009

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
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1.Well Contractor Information:
Kevin White 14.WATER ZONES
_FROM TO DESCRIPTION
Well Contractor Name 43 ft. 50 ft' I I wet
2973 ft. ft. I !
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap.Iicable)
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' 40 ft. 2 in. sch40 pvc
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
rt. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 40 ft. 50 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
❑Irrigation 0 ft, 35 ft• Portland Cem Pour
Non-Water Supply Well:
❑O Monitoring ❑Recovery
35 ft. 38 ft• Bentonite Chi! Pour
Injection Well: ft, ft.
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK(if applicable) -
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
38 ft. 50 rt. #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage -
ft. ft.
El Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional 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. r..-7-7, _ ^^T
4.Date Well(s)Completed: 8-30-23 Well ID# MW-4D it,° ^t ,,, ___ h
ft. ft. OCT �
Sa.Well Location: ft. ft. Jr �' t -Ll1L3
Hallstar Greensboro LLC Former Lanxess Bldg ft, ft. intuit:,::f.2.n t r;-
Facility/Owner Name Facility ID#(if applicable) -- ft. ft. t;•'•-::/;
520 Broome Road, Greensboro ft. ft.
Physical Address,City,and Zip 21.REMARKS
Guilford 7873030812 2 x 2 Pad
County Parcel Identification No.(PIN) 8°FMC •
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: '
(if well field,one lat/long is sufficient)
36.039432 N -79.777848 W \eVLkt.-\ (k).(\G , q 1 • ' Z
Signature of Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or ElTemporary By signing this form,I hereby cert&that the well(s)was(were)constructed in accordance
with ISA 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,.frl/out known well construction information and explain the nature of the
repair under 421 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 the same construction.you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 50 (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'and 2@l00') construction to the following:
10.Static water level below top of casing: 43 (ft,) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 10 15 (in.) 24b. For Injection Wells ONLY: Inladdition to sending the form to the address in
NSA/Air Hammer 24a above, also submit a copy of this form within 30 days of completion of well
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(gpm) Method of test: 24c.For Water Supply&Injection Wells:
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.
Fonn GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013