GW1--06427_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
1.Well Contractor Information:
Kevin White 14.WATER ZONES l ,
FROM TO DESCRIPTION
Well Contractor Name 7 ft. 17 ft 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. 7 ft. 2 in' sch40 pvc
List all applicable well permits(i.e.County,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 7 ft... 17 ft. 2 '"' 010 sch40 pvc
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) f`' f`' in.
PPY) PPY
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 3 ft Portland Cem Pour
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft. 5 ft Bentonite Chii 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
5 ft. 17 ft. #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.
8-29-23 MW-17 ft. ft. -
4.Date Well(s)Completed: Well ID# - ft. ft. '.%' -,?L -
1`' s -'5a.Well Location: ft. ft.
Hallstar Greensboro LLC Former Lanxess Bldg ft. ft QCI 9022
Facility/Owner Name Facility ID#(if applicable) ft. ft. 1f FJ "-C 7 ['''' =`_' is :i
520 Broome Road, Greensboro r,,::..,, �
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.Certification:
(if well field,one lat/long is sufficient)
36.037999 N -79.778552 N ,��,‘-\ W\� 9 • , ?-a�
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ❑Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with ISA NC'AC 02C.0/00 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo 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 the some construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 17 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple we/Ls list all depths if different(example-3@200'and 2@/00') construction to the following:
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10.Static water level below top of casing: 7 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"- 1617 Mail Service Center,Raleigh,NC 27699-1617
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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.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
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. 1
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Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013