GW1--06424_Well Construction - GW1_20231009

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WELL CONSTRUCTION RECORD For Internal Use ONLY: I
This form can be used for single or multiple wells
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1.Well Contractor Information:
Kevin White 14.WATER ZONES I '
' FROM TO DESCRIPTION
Well Contractor Name 12 ft. 25 ft• I VVet
2973 ft. ft.
NC Well Contractor Certification Number 15.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)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 15 ft 2 ; to sch40 pvc
List all applicable well permits(i.e.C'ounty,Slate,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 15 ft. 25 ft. 2 in. 010 sch40 pvc
OGeothermal(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• 11 ft• Portland Cem Pour
Non-Water Supply Well:
❑O Monitoring ❑Recovery 11 ft13 ft• Bentonite Chi! Pour
Injection Well: ft. ft.
ElAquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
13 ft• 25 fL #1 Sand Pour
❑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,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
ft. ft.
4.Date Well(s)Completed: 8-31-23 Well ID# MW-11 ft. ft. •
,_M+ a_-F i ;�
5a.Well Location:
ft. ft.
Hallstar Greensboro LLC Former Lanxess Bldg ft. ft. OL I 0 :9 2023
Facility/Owner Name Facility ID#(if applicable) ft. ft.
520 Broome Road, Greensboro
ft. ft. D Or3017
Physical Address,City,and Zip
21.REMARKS
Guilford 7873030812 2 x 2 Pad -- _-
County Parcel Identification No.(PIN) 8"Flush Cover
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
36.039517 N -79.779258 w °is r,-, \c\A�. R. (2 • 3,I
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,1 hereby certify that the well(s)was(were)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 ENo 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 provide additional well site details or well
8.Number of wells constructed: 1 to 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: 25 (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@100') construction to the following:
10.Static water level below top of casing: 12 (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 (in.) 24b. For Injection 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
(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. ! .
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Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Res iurces Revised August 2013