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WELL CONSTRUCTION RECORD(GW-1) For Internal Use'Only:
1.Well Contractor Information:
JOHNNY BURR 14.WATER ZONES 1
FROM TO DESCRIPTION
Well Contractor Name ft. It.
A - 3098
ft. rt.
NC Well Contractor Certification Number 15.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• 14.0 ft• 2.0 in* SCH 40 PVC
3.Well Use(check well use): ft. It. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 14.0 ft' 29.0 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) 18.GROUT '
❑Irrigation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 5.0 ft. PORTLAND BENTONITE SLURRY
IlMonitoring ❑Recovery ft. ft.
Injection Well:
It. 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 12.0 ft. 29.0 ft. 20-40 FINE SILICA SAND
0 Experimental Technology ❑Subsidence Control ft. ft.
OGeothermal(Closed Loop) OTracer 20.DRIL LING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
0.0 ft. 7.0 ft• RED/ORANGE CLAY
4.Date Well(s)Completed: 10/07/21 Well ID# MW-4 7.0 ft• 29.0 ft. TAN SILTY CLAY
5a.Well Location: ft. ft.
A CLEANER WORLD ft. ft. . --
ft. ft.
Facility/Owner Name Facility IN(if applicable)
3735 PETERS CREEK PARKWAY WINSTON SALEM 27127 ft. ft. MAR 1 4 2fl7'
Physical Address,City,and Zip ft. ft.
FORSYTH 21.REMARKS
BENTONITE SEAL-5.0-12.0 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 604-61
u'� 10/19/21
6.Is(are)the well(s): Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,/hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo ISA NCAC 02C.0100 or ISA 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#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-I 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: , 29'0 (ft.)
For multiple wells list all depths i/'different(example-3(a 200'and 2 a@100') Submit this GW-1 within 30 days dwell completion per the following:
10.Static water level below top of casing: 1 6.0 (ft) 24a. For All Wells: Original form,to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above caving,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
i
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 2 7699-1 61 1
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
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Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018