GW1-2022-08782_Well Construction - GW1_20220909

F ;Print Form ,
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information:
Wesley J. Sorrells 14.WATER ZONES;�,,:. k:. . .
Well Contractor Name FROM TO I DESCRIPTION
3577 ft. ft.
rL rL
NC Well Contractor Certification Number A5.,OUTER CASING for-multi cased;wells OR LDVER if:a' licible
Terraquest Environmental Consultants FROM To DIAMETER THICIavesS MATERIAL
Company Name
0 rL 40 rL 1 ' 1" Sch 40 1 PVC
16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: FROM TO I DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.U1C,County,State, Variance,etc.) ft ft. in,
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL___
Agricultural OMtmicipal/Public 40 fL 45 fL 1 i":1 10 Sla• Sch. 40 P C
Geothermal(Heating/Cooling Supply) QResidential Water Supply(single) ft. ft. in.
IndustriaUCommercial EIResidential Water Supply(shared) A&GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD AMOUNT
Non-Water Supply Well: 36 ft. 38 ft- Bentonite Pour
Monitoring _ Recovery 0.5 fL 36 fL Portland Pour
Injection Well: fL fL
Aquifer Recharge BGroundwater Remediation
,19.SAND/GRAVEL PACK if a 'lieible _
Aquifer Storage and Recovery �i Salinity Barrier FROM TO MATERIAL EMPLACEMENTM OD
Aquifer Test 13 Stormwater Drainage 38 fL 45 fL No. 2 Sand Pour
Experimental Technology QSubsidence Control fL ft.
Geothermal(Closed Loop) Tracer �1.20.DRILLING LOG attach'additional sheenif necessary)
Geothermal(Heating/CoolingReturn Other(explain under#21 Remarks FROM TO DESCRHPTION color,hardness,soil/rock gain sin,eto
0 fL 0.5 fL Topsoil
4.Date Well(s)Completed:4/20/2022 well ID#AS1 0.5 fL 5 It. Silty Lean Clav
5a.Well Location: 5 fL 45 ft- Silt
Quality Mart#18 0-016670 fL fL
Facility/Owner Name Facility ID#(if applicable) fL fL
3011 Waughtown St Winston-Salem, NC 27107
Physical Address,City,and Zip fL ft.
Forsyth 6854-19-5111
,'2L REMARKS '
County Parcel Identification No.(PIN) --
y.J11:rQ :iQ�7
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
36.0772 N 80.1792 W ��%
�� �.- 4/20/22
6.Is(are)the well(s)OPermanent or Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 13Yes or EnNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 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 site details or well
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 45 (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@200'and 2@100') construction to the following:
10.Static water level below top of casing:NW (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method:
Solid Stem Auger above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,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 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.
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources' Revised 2-22-2016