GW1--06426_Well Construction - GW1_20231009

l
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells '
1.Well Contractor Information:
Kevin White 14.WATER ZONES 1
FROM TO DESCRIPTION
Well Contractor Name 6.5 ft. 16 ft. I wet
2973 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
FROM TO DIAMETER THICKNESS l 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 in' .010 sch40 pvc
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply fr. ft in.
( � g PPY) PPY
❑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:
❑O Monitoring ❑Recovery 2 ft. 4 ft. Bentonite Chi! Pour
Injection Well: ft. ft. I
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
4 ft• 16 ft• #1 Sand Pour
❑Aquifer Test ❑StormwaterDrainage - ---
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
EGeothermal(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. ,
8-30-23 MW-16 ft. ft.
4.Date Well(s)Completed: Well ID# ft. ft. _ _ 17.` .t 7-7-..�-,
5a.Well Location: ft. ft. ,: 4;�ate,E...,. �Y A...,:=y'
Hallstar Greensboro LLC Former Lanxess Bldg ft. ft. ' OCT a 9 ?n23
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
520 Broome Road, Greensboro ft. ft. if)""sc "`'' P!... '•,,.;z;,s 1,t,;i
Physical Address,City,and Zip r i'•_`;ii'z i Y{-1
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.Certification:
(if well field,one lat/long is sufficient)
36.038254 N -79.778808 w ki\ 11,1 L\\.N q. i g •a I
Signature of Certified Well Contractor Date
6.Is(are)the well(s): @Permanent or ❑Temporary By signing this form,i hereby certifi,that the well(s)seas(were)constructed in accordance
with 15A NC'AC 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.
1f this is a repair,fill out known well construction information and explain the stature of the
repair under x21 remarks section or at the hack of this form. 23.Site diagram or additional welldetails:
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 sane 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
/'or multiple wells list all depths ifdifferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 6.5 - (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 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.) 1
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test: _
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county healttr department of the county where
constructed.
Fonn GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013