GW1--04087_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 19.81 ft 31 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 1 ft. MATERIAL
A (� 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• 16 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
DAgricultural DMunicipal/Public 16 ft 31 ft 2 in' 0.010 sch40 PVC
J- Geothermal(Heating/Cooling Supply) DResidential 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 13 ft Bentonite Poured/250LB
Monitoring DRecovery 0 ft 3 ft. Neat Cement Poured/60LB
Injection Well:
ft. ft.
Aquifer Recharge OGroundwater Remediation 19.SAND/GRAVEL PACK(if applicable) -
DAquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage 13 ft 31 ft• #2 Sand Poured
Experimental Technology 0 Subsidence Control ft. ft. 1
DGeothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets if necessary)
ri
Geotheririal(Heating/Cooling Return) X' Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grin size,etc.)
ft. ft. See Consultant Log
4.Date Well(s)Completed:6/8/2023 Well ID# W3-13 it ft. p`' i i- "_. .. I a�f
4 .ice_(t it......i 11 Imo-! ;.
5a.Well Location: ft. ft •
Former Manufacturing Facility ft. ft. JOIN ', 2 2023
Facility/Owner Name Facility ID#(if applicable) ft. ft. lnr f i n rcc 3f+f 1lt,
2744 West Mountain St. Winston-Salem 27284 ft. ft. DVIC.1/8OG
Physical Address,City,and Zip ft. ft
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 N 80 09 45 W - �`,,6. 6/9/2023
6.Is(are)the well(s)JPermanent or QITemporary Signature'rtified Well Contractor Date
By signing this form,1 hereby certtbi that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: tYes or EjNo with ISA 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 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: 31 (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 topof casing: 19.81
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
Auger above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: g
(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&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
u
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