GW1--06425_Well Construction - GW1_20231009

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 I
FROM TO DESCRIPTION
Well Contractor Name 5 ft• 16 fL I wet
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. 6 ft. 2 i"• 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 6 ft 16 ft 2 i" .010 sch40 INC
ft. ft. in.:
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18,GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 2 ft- Portland Cem Pour
Non-Water Supply Well:
oMonitoring DRecovery 2 ft 4 ft• Bentonite Chii Pour
Injection Well: ft. ft
DAquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable) _
FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Storage and Recovery ❑Salinity Barrier
DAquifer Test ❑StormwaterDrainage 4 ft' 16 fL #1:Sand Pour
ft. ft.
DExperimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer 1 FROM TO DESCRIPTION(color,hardness,soiUrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) ft. ft.
8-29-23 MW-19 ft. ft. r,
- ` ? ° • r-_
4.Date Well(s)Completed: Well ID# ft. ft
1 ^"_`r 'dI`L77
5a.Well Location: ft. ft. ill.1 0 9 2023
Hallstar Greensboro LLC Former Lanxess Bldg ft. ft.
uru;n;':-.:•-, %)r-..7,,,,,:,..., I r...:,
Facility/Owner Name Facility ID#(if applicable)
ft. ft. Y.! ..'Li
520 Broome Road, Greensboro ft. ft.
Physical Address,City,and Zip 21.REMARKS
Guilford 7873030812 2,x 2 Pad
County Parcel Identification No.(PIN) 4"Pro Cover
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Cer Tication:
(if well field,one lat/long is sufficient) rr `` `
1~
36.037771 N -79.776840 w l� W l 9 . 1 S.a 3
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(.$)was(were)constructed in accordance
with 1.5A 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 r21 remarks section or on the hack ofthis 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: 16 (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@/00') construction to the following:
10.Static water level below top of casing: 5 (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: 1 0 (in.) 24b. For Iniection 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: 1-IS/4 construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield a m Method of test: 24c.For Water Supply&Injection Wells:
(bp ) 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-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013