GW1-2022-07694_Well Construction - GW1_20220818

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
NICHOLAS HAYES 14.WATERZONES"
FROM TO DESCRIPTION
Well Contractor Name _
ft. ft. R
A - 4121 �_G I V_ ft. ft.
NC Well Contractor Certification Number I5:OUTER CASING for multi-cased wells OR LINER•if a`'licable -`
GEOLOGIC EXPLORATION AUG 1 S 2022 FROM TO DIAMETER THICIQVESS MATERIAL
ft. ft. in.
Company Name If1iCi r� :C 1 �,' `.rJ Ihii 16.INNER CASING OR TUBING eothermal'closed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) 0.0 ft• 30.0 ft 2.0 1°' SCH 40 PVC
3.Well Use(check well use): tr. ft. in.
Water Supply Well: FROM REENTO DIAMETER SLOT SIZE THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public 30.0"' 50.0 ff 2.0 in' .010 ScH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) i8.GROUT
❑Irrl atlon ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 fL 23.0 ft' PORTIANDaENTONITE SLURRY
[EMonitoring ❑Recovery tt. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19:SAND/GRAVELPACK(if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 28.0 f` 50.0 ft' 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20i DRILLING LOG attach additiorial`sheets iFriecessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTIONcolor hardness,soil/rock rain size,etc.
0.0 ft- 5.0 ft• RED CLAY
4.Date Well(s)Completed: 05/24/22 Nell ID# MW-2 5.0 1- 15.0 It- RED HARD SILT
Sa.Well Location: 15.0 ft' 20.0 ft' PWR
QUALITY PLUS 20.0 ft 50.0 ft• ROCK
Facility/Owner Name Facility ID#(if applicable) ft- ft. '
2265 OLD SALISBURY ROAD WINSTON SALEM 27127 rt. ft.
Physical Address,City,and Zip ft. ft.
FO RSYTH 21;REMARKS
County Parcel Identification No.(PIN) BENTONUE SEAL-23.0-28.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I -
(if well field,one Iat/long is sufficient) 22.Certification:
360 02' 16.48" N 800 16' 20.01" W 06/10/22
6.Is(are)the well(s): Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,/hereby cert fy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 01C.0100 or 15A 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#21 remarks section or on the back ofthis 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: 50.0 (ft.)
For multiple wells list all depths tfdifferent(example-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
29.0 24a. For All Wells: Original fornT to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617iMSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
6 0 24b. For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR
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 producine`over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
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
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