GW1--04074_Well Construction - GW1_20230622

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Terry White .14:WATER ZONES-
Well Contractor Name FROM TO DESCRIPTION
3287-A 21.30 ft. 35 ft.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
I ET FROM TO DIAMETER THICKNESS MATERIAL
ft ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop) -. - - _ -
2.Well Construction Permit#:W'o4O0599 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0 ft. 20 ft. 2 in' sch40 PVC
3.Well Use(check well use): ft ft in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER , SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public 20 ft• 35 ft• 2 in' 0.010 sch40 PVC
Geothermal(Heating/Cooling Supply) 0 Residential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 3 ft. 17 ft• Bentonite Poured/325LB
Monitoring 0Recovery 0 ft 3 ft- Neat Cement Poured/60LB
Injection Well: ft. ft.
Aquifer Recharge 0 Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage 17 ft. 35 ft• #2 Sand Poured
Experimental Technology 0 Subsidence Control ft. ft
Geothermal(Closed Loop) 'Tracer 20.DRILLING LOG(attach additional sheets if necessary) . -.
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rocktype,grain size,etc.)
ft ft• See Consultant Log
4.Date Well(s)Completed:6/8/2023 Well ID#IW3-11 ft ft.
ft. ft. o. -,..a^z,
5a.Well Location: rr 7•'f i p q IF 4 ,
Former Manufacturing Facility ft ft i "t. ..' 'I-.-1 `�
Facility/Owner Name Facility ID#(if applicable) ft. ft. .J I i I V 9. 2 2023
2744 West Mountain St. Winston-Salem 27284 ft ft :; Ur.!;
ft ft tnk,..Tn7S :%i..'�:•:.�.+'••
Physical Address,City,and Zip DVK3i "O{a
Forsyth 21.REMARKS
County Parcel Identification No.(PIN)
Injection Well for Remediation
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lot/long is sufficient) 22.Certification:
36 06 49 N 80 09 45 W 6/9/2023
6.Is(are)the well(s)Jx Permanent or Temporary Signature ofC ued Well Contractor Date
By signing this form,I hereby certfy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: fYes or DINo with 15A NCAC 02C.0100 or 1SA NCAC 02C.0200 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#11 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:one SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 35 (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@l00) construction to the following:
10.Static water level below topof casing:21.30
g (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:8 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Augerabove,also submit one 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 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 SUDDIV&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.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016