GW1--06428_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
1.Well Contractor Information:
Kevin White 14.WATER ZONES i
FROM TO DESCRIPTION
Well Contractor Name 7 ft- 18 IL I wet
2973 ft. ft. 1 '
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. 8 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 8 ft. 18 ft• 2 '"' .010 sch40 PVC
ft. ft. to•
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(sin le)
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
FROM TO _ MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft' 4 ft- Portland Cem Pour
Non-Water Supply Well:
❑o Monitoring ❑Recovery 4 ft• 6 ft. Bentonite Chii Pour
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
6 ft• 18 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) ElOther(explain under#21 Remarks) ft. ft.
9-1-23 MW-15 ft. ft. V,_�;_.(' i.,t 1art_Fes,
4,Date Well(s)Completed: Well ID# �' °a_ r 6 •, n'
ft. ft 5a.Well Location: ft. ft O C IT
0 2UZ3
Hallstar Greensboro LLC Former Lanxess Bldg ft. ft Info„r :2❑ ,r r17.. ,.�s)I(1-i
Facility/Owner Name Facility lD#(if applicable) ft. ft DW',r
I OG
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"Flush Cover
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)_
36.03931 N -79.77867 wV` \\� � q. I 'P• a a
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.2l remarks section or on the back 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: 18 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 7 _(ft.) Division of Water Resources,Information Processing Unit,
lf water level is above casing,use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For Injection Wells ONLY: In addition to sending the form to the address in
HSA/ DPT 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.) 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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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 health department of the county where
constructed.
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Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resi ones Revised August 2013