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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
CARL CARPENTER 14.WATER ZONES .
FROM . TO .DESCRIPTION _
Well Contractor Name ft. ft.
A - 4475 ft. ft. .
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER THICKNESS �.MATERIAL
GEOLOGIC EXPLORATION, INC ft. ft.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop) '
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0.0 ft• 10.0 ft' 2.0 ; '"• SCH 40 PVC
List al/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 ❑Municipal/Public 10.0 ft' 25.0 ft• 2.0 '"' .010 SCH 40 PVC
OGeothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Olndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrrlgatton 0.0 ft 5.0 ft PORTLAND:BENTONITE SLURRY
Non-Water Supply Well: '
ft. ft.
OMonitoring ORecovery
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 OSubsidence Control
20.DRILLING LOG(attach additional sheets if necessary).,
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0.0 ft 2.0 ft ASPHALT/GRAVEL
11/02/21 MW-2 2.0 ft 10.0 ft RED CLAY
4.Date Well(s)Completed: Well ID#
10.0 ft• 20.0 ft* . BROWN CLAY
5a.Well Location:
ONE HOUR MARTINIZING 20.o ft. 25.0 ft' TAN SILTY SAND
ft. ft. 1 '.Facility/Owner Name Facility ID#(if applicable) MAR I '1 ?n?7
ft. ft.
3520 YADKINVILLE ROAD WINSTON SALEM 27106 ft. ft.
Physical Address,City,and Zip •
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21.REMARKS
FORSYTH BENTONITE SEAL-5.0-8.0 FEET
County Parcel Identification No.(PIN)
fib.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" W < -.- 11/16/21
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By j. certify () (were)signingthis Orm,I herebythat the wells was constructed in accordance
with/SA NCAC 02C.0100 or 1 5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ❑No 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#2l 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 one jernt. 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 wells list all depths if different(example-3 n 200'and 2 r@i/00') construction to the following:
10.Static water level below top of casing: 12.0 (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 8.0 (in.) 24b. For Injection Wells: In addition to sending the form to the address in 24a
AUGER above, also submit a copy of this'form within 30 days of completion of well
12.Well construction method: 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&Injection I 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. 11
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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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