GW1--04078_Well Construction - GW1_20230622

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: I
Terry White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 30.34 ft 55 k
•
3287-A
ft ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi cased welts)OR LINER(if op livable)
I ET FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. . in.
Company Name
WI 0400599 16.INNER CASING OR TUBING(geothermal closed-loop) -
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0 ft 40 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 QMunicipaVPublic 40 ft 55 ft 2 in' 0.010 sch40 PVC
Geothermal(Heating/Cooling Supply) D 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. 37 ft. Bentonite Poured/655LB
Monitoring 0Recovery 0 ft 3 ft Neat Cement Poured/60LB
Injection Well: ft. ft.
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable) -
Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage 37 ft 55 ft #2 Sand Poured
Experimental Technology D Subsidence Control ft ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
GeothermalFROM TO DESCRIPTION(color,hardness,soil/rock type,grain size.eta)
(Heating/Cooling Return) PI (explain under#21 Remarks) ft. ft
See Consultant Log
4.Date Well(s)Completed:6/8/2023 Well ID#IW2-5 ft. ft.
5a.Well Location: ft. ft. rn 7,
f'f7.t' / 1r,,,i
Former Manufacturing Facility ft. ft. t L.e,-r 4.--; V ,. L
Facility/Owner Name Facility ID#(if applicable) ft. ft. J I J N 2 ? 2023
2744 West Mountain St. Winston-Salem 27284 ft ft l �V
Physical Address,City,and Zip ft. ft. Int'Crr-r:a:1L i I Pi G^..: t45rir'n`g link
[}4-013 C
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 lat/long is sufficient) 22.Certification:
36 06 49 80 09 45 6/9/2023
N W /7 0)46-
6.Is(are)the well(s)JX Permanent or Temporary Signature ofCe ed Well Contractor Date
By signing this form,I hereby cert fy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: fYes or ,xENo with 15A NCAC 02C.0100 or 15A 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#21 remarks section or on the back of this fonn.
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: 55 (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:30.34 (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 Sunnlv&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