GW1--04091_Well Construction - GW1_20230622

Jr Print,Form -I
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: i
1.Well Contractor InformatioD: •
1
Terry White 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3287-A 25.90 ft• 42 ft• j
ft. ft.
NC Well Contractor Certification Number 15;OUTER CASING(for multi-cased wells)OR LINER(if ap livable)
I ET FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
WIO/jO®GQ[a -.16.INNERCASINGORTUBING(geothermalclosed-loop) -
2.Well Construction Permit#: T 59 V FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0 ft• 27 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 DMunicipal/Public 27 ft• 42 ft- 2 in• 0.010 sch40 PVC
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft, ft. in
Industrial/Commercial DIResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 3 ft- 24 ft. Bentonite Poured/450LB
Monitoring ORecovery 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 OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage 24 ft- 42 ft• #2 Sand Poured
Experimental Technology DiSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) MOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain sae,etc.)
ft.
t ft• See Consultant Log
4.Date Well(s)Completed:6/8/2023 Well ID#I W3-8 ft. ft.
I ft. ft. :. �,� '
5a.Well Location: 1. C
Former Manufacturing Facility ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. J G i V 2 d l U 13
2744 West Mountain St. Winston-Salem 27284 ft. ft.
Infrr: !jr.n nrm F3 Lir0
Physical Address,City,and Zip ft ft DWCtia0G
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 G€ 6/9/2023
6.Is(are)the well(s)1Permanent or Temporary Signature of itified Well Contractor Date
By signing this form,1 hereby certfy that the well(s)was(were)constructed in accordance
7.Is this a repair to art existing well: FJYes or xNo 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:
S.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:42 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiferent(example-3@200'and 2@I00') construction to the following:
10.Static water level below top of casing:25.90 (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 Sum*&Iniection 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