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WELL CONSTRUCTION.RECORD For Internal Use ONLY:
This form can be used for single or multiple wells 1
1.Well Contractor Information: j '
CARL CARPENTER 14..WATER ZONES -uEscRlrmo FROM TO _ N -
Well Contractor Name ft. ft. 1
A - 4475 ft, ft.
NC Well Contractor Certification Number 15.OUTER CASING(for Multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER s. THICKNESS MATERIAL
GEOLOGIC EXPLORATION, INC ft. ft. ! in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS _ MATERIAL
2.Well Construction Permit#: 0.0 ft' 10.0 rt' 2.0 1°' SCH 40 PVC
List all applicable well construction permits(i.e.County,State,Variance,etc.) ft. ft. _in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: -FROM TO DIAMETER : SLOT SIZE THICKNESS MATERIAL '
❑Agricultural OMunicipal/Public 10.0 ft' 25.0 ft 2.0 1°'j .010 SCH 40 PVC
ft. ft. in.(Heating/Cooling Supply) ❑Residential Water Supply(single)
Olndustrial/Commercial ❑Residential Water Supply(shared) 18•GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0.0 ft. 5.0 ft. PORTLAND BENTONITE SLURRY
Non-Water Supply Well: ft. ft.
0 Monitoring ❑Recovery -
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 8.0 ft• 25.0 ft. 20-40 FINE SILICA SAND
❑Aquifer Test OStormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
.20:DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
OGeothermal(Heating/Cooling Return) ❑Other.(explain under#21 Remarks)" 0.0 ft. 2.0 It ASPHALT/GRAVEL
11/01/21 MW-3 2.0 it 10.0 ft• RED CLAY
4.Date Well(s)Completed: Well ID#
10.0 ft• 20.0 ft BROWN CLAY
5a.Well Location: 20.0 ft• 25.0 ft TAN SILTY SAND
ONE HOUR MARTINIZING ft. ft.
Facility/Owner Name Facility 1D#(if applicable) ft. ft.
3520 YADKINVILLE ROAD WINSTON SALEM 27106 ft. ft. MAR 1 i 2022
Physical Address,City,and Zip 21.REMARKS
FORSYTH BENTONITE SEAL,-f_5.0-8.0 FEET
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient) /�
36° 09' 09.94" N 80° 18' 47.42" G - 11/16/21
Signature of Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or OTemporary By signing this form,I 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 ONo 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 1121 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 same construction,you can
submit oneJorm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 25'0 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple we/Is list all depths if different(example-3�00'and 2 rer 100) construction to the following:
10.Static water level below top of casing: 12'0 (ft.) Division of Water Quality,Information Processing Unit,
1f water level is above casing,use"+•• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8 0 (in.) 24b.For Injection Wells: 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: AUGER construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,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 Sr lniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of 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 Quality Revised Jan.2013
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