GW1--04092_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 27.50 fL 40 ft-
ft. rt.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
IET FROM TO DIAMETER THICKNESS MATERIAL
fL ft. in.
Company Name W 10400599 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• 25 rt• 2 in' SCh44 PVC
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipa1Public 25 fL 40 ft- 2 in' 0.010 sch40 PVC
Geothermal(Heating/Cooling Supply) E3Residential Water Supply(single) ft. ft. in.
Industrial/Commercial 0Residential Water Supply(shared) IS.GROUT '
! Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 3 ft• 22 fL Bentonite Poured/450LB
Monitoring ORecovery 0 ft' 3 fL Neat Cement Poured/60LB
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery E3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStorrnwater Drainage 22 fL 40 ft• #2 Sand Poured
Experimental Technology D Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) f Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soilrock type,grain size,etc.)
ft. f• See Consultant Log
4.Date Well(s)Completed:6/8/2023
Well ID#IW3-7 ft. ft.
5a.Well Location: ft ft. t X 'fir E t j fEl
Former Manufacturing Facility ft. ft. `
Facility/Owner Name Facility ID#(if applicable) ft. ft. JUN r
2744 West Mountain St. Winston-Salem 27284 11, rt. 1nt'i,fry'P4;l m Pry;;, r Lli-,.;
Physical Address,City,and Zip ft. ft. Ctitity
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 0,116&. 6/9/2023
6.Is(are)the well(s)IPermanent or E3Temporary Signature Certified Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: lYes or jNo 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 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: 40 (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:27.50
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 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
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