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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: '
1.Well Contractor Information:
JOHNNY BURR 14.WATER ZONES h
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
A - 3098
ft. ft. I
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS 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.U/C,County,State,Variance,etc.) 0.0 ft. $0 ft 2.0 ; in* SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 8.0 ft* 23.0 ft' 2.0 in' .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 4.0 ft- PORTLAND BENTONITE SLURRY
IEMonitoring ❑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 6.0 ft. 23.0 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) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
0.0 ft• 9.0 ft• RED/ORANGE CLAY
4.Date Well(s)Completed: 10/07/21 Well ID# MW-2 7.0 ft• 26.0 ft. TAN SILTY CLAY
ft. ft.
5a.Well Location:
A CLEANER WORLD ft. ft.
•
ft. ft. t
Facility/Owner Name Facility ID#(if applicable) -
3735 PETERS CREEK PARKWAY WINSTON SALEM 27127 ft. ft.
MAR 1 2O2
Physical Address,City,and Zip
ft. ft. ,
FORSYTH 21.REMARKS
BENTONITE SEAL'4.0-6.0 FEET
County Parcel Identification No.(PIN) "'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
36° 01' 10.68" N 80° 15' 36.90" W G 16''"..,
10/19/21
6.Is(are)the well(s): LlPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,/hereby certify that the sell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ENO ISA NCAC 02C.0/00 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,Jill out known well construction information and explain the nature of the of this record has been provided to the well'Owner.
repair tinder#2/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: 23•0 (ft.)
For multiple wells list all depths if different(example-9 rev 200'and 2�a/00') Submit this GW-1 within 30 days of Well completion per the following:
16.0 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 27699-1 61 1
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018