GW1-2022-08409_Well Construction - GW1_20220527

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID HALL 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
fr. ft
A - 4459 fr. fr.
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER ifa licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
16:INNER CASING OR TUBING. eothermal closed-loo`
2.Well Construction Permit#: FROM I TO DIAMETER I THICKNESS I MATERIAL
List all applicable ivell construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 ft. 12.5 ft. 2.0 1° SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 12.5 ft- 27.5 ft' 2.0 in- .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT"
❑Irrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft• 7.0 It' PORTLAND BENTONRE SLURRY
1!9Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier 19.SAND/GRAVEL PACK(if a licahleFROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 10.0 ft. 27.5 ft. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING'LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) FROM I TO DESCRIPTION color,hardness,soil/rock a grain size,etc.
0.0 ft. 7.0 ft. SANDY SILTY CLAY
4.Date Well(s)Completed: 05/18/22 Well 1D# MW-5 7.0 ft. 27.5 ft- SILTY SANDY PWR
Sa.Well Location:
ft. ft.
A CLEANER WORLD - 150 ft. ft.
Facility/Owner Name Facility ID#(if applicable) rt. ft.
3735 PETERS CREEK PARKWAY WINSTON SALEM 27127 ft. ft.
Physical Address,City,and Zip ft. ft.
FO RSYTH 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-7.0-10.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
36e 01' 10.68" N 800 15' 36.90" W 05/26/22
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the ivell(s)ivas(ivere)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or [!5No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known ivell construction information and explain the nature of the of this record has been provided to the well owner.
repair tinder i121 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 addi o I ell construction info
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach a L tonal pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 27.5 MAY 2 7 26 22
For multiple ivells list all depths ifdierent(example-3@,200'and 2@100) (ft.) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 20.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+^ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
8.0 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: 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 roducin over 100 000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC, aleigh,NC 27699-1 61 1
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018