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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JOHNNY BURR 14.WATER ZONES I. s
Well Contractor Name FROM TO DESCRIPTION
ft. ft. f
A - 3098 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if appIlicable)
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS I MATERIAL
ft. ft. I 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• 'MO ft• 2.0 in' SCH 40 PVC
3.Well Use(check well use): B. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 1 1.0 ft. 26.0 ft• 2.0 In' .010 SCH 40 PVC
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) ts.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 5.0 ft• PORTLANDBENTONITE SLURRY
lMonitoring ❑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 ❑StormwaterDrainage 9.0 ft. 26.0 ft. 20-40 FINE SILICA SAND
0 Experimental Technology OSubsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
0.0 ft• 7.0 ft RED/ORANGE CLAY
4.Date Well(s)Completed: 10/06/21 Well ID# MW-1 7.0 ft• 26.0 ft• TAN SILTY CLAY
ft. ft.
5a.Well Location:
A CLEANER WORLD ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. t% _..._._ r.; r_ ,_�°
3735 PETERS CREEK PARKWAY WINSTON SALEM 27127 ft. ft. MAR 1 4 2029
ft. ft.
Physical Address,City,and Zip
FORSYTH 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL' 5.0-:9.0 FEET. .' '.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: QQ
36° 01' 10.68" N 80° 15' 36.90" W G `6Z'Y`' 10/19/21
6.Is(are)the well(s): MPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the we/l(s)teas(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 21No 15A NCAC 02C.0100 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 under#21 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: 26'0 (ft.)
For multiple wells list al/depths if different(example-3(a 200'and 2@I00') Submit this GW-1 within 30 days of well completion per the following:
17.0 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 fiver 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
•
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources'j Revised 6-6-2018