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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID HALL 14.WATERZONES t
Well Contractor Name FROM _ TO DESCRIPTION
It. ft. I
A - 4459
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-eased livens)OR LINER(if ap licable)
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS lf MATERIAL
ft. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 ft• 48.0 ft. 2.0 in' SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
PPY FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 48.0 ft• 50.0 ft' 2.0 1n' .010 SCH 40 PVC
OGeothennal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft' 42.0 ft' PORTLAND BENTONITE SLURRY
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 45.0 ft. 50.0 ft' 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) l Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
0.0 ft. 50.0 ft' RED CLAY
4.Date Well(s)Completed: 09/22/21 Well ID# AS-18 ft. ft.
ft. ft.
5a.Well Location:
SPEEDWAY- 6933 ft. ft. yp
Facility/Owner Name Facility IDb(if applicable) ft. ft. A� 42�2e -
2420 SOUTH STRATFORD ROAD WINSTON SALEM 27103 ft. ft.
ft. ft.
Physical Address,City,and Zip
FORSYTH 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL'42.0-45.0 FEET
***AIR SPARGE***
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22.Certification:
36° 03' 13.40" N 80° 19' 16.33" W 6 / -e 09/29/21
6.Is(are)the well(s): I!JPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby cert that the well(s)was(here)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ElNo 15A NCAC 02C.0100 or/SA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under 112/remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: SO.O (ft.)
For multiple wells list all depths if different(example-3 a 200'and 2@/00') Submit this GW-1 within 30 days of well completion per the following:
30.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft') Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: 8.0 (in.) 24b. For Injection Wells: Copy to DWR,Underground Injection Control (IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,'NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount: '
i
Fonts GW-I North Carolina Department of Enviromnental Quality-Division of Water Resources Revised 6-6-2018