GW1--04713_Well Construction - GW1_20230721

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well.Coutr star Information:
.t.tiWATER.ZONtS
Scott Hunt, Jr FROM TO DESCRIPTION
«2RConingorName 79 ft. it. rock fracture
4561-A R. fL l • .
NC Weil CaNraeiorCcr(iftrationNurrber AS:OUTER CASING(formuhl-c9oedfaelslOR-LINER(ifiin Neat,k)
FROM • TO DIAMETER TWA-NESS' MATERIAL
SAEDACCO Inc 0 ft. 73 ft. 6 in; SCH-40 - Carbon Steel
Company Nance 16:INNER CASING OR.TUBING tioatiernal closed-loon)
FROM TO DIAMETER TRIMNESS ' MATERIAL
2.Well Construction Permit sr: R. ft. tn.
List ufl applir;able well permits(L..County Slam,Variance.16recdar;or.)
R. ft.• im,
3.Well Ilse(check well use): . I7:SCREEN
Water Supply Wdl: • _- r - FROM TO DiAME.TER SLOT-RIM T111CKN0S MATERIAi, .
•iJAgiicultutml, , ClMunicipal/Public 73 ft, 83' R. 6 in. NA NA NA
iCooli Supply) ®Residential Water Supplyft. ft. in.
OGeothamal(Heath
n13i nS uPP (single)
®litdustfiallConmtereial - ®Residential Water Supply(slated) Ie'CROUT
FROM - TO - MATERIAL ' EMPIACEMLIT 1HEf1100&AMOUNT
❑hripation 0 it. 73 ' tt. Portland 'Tremie
Noa-Water Supply Well: .
(Monitoring DRccavcty . D• ft.
Injection Welt: • - ft. ft. .
ClARuifcr Reel:dirge . iaGioulidiiatcr Rcntcdiation . • -•Iv:SAND/GRAVEL wick(ir aytpliest
•FROM TO arATE.RIAI. EmPI.A(a IENTNITHOn
lJArluifcr Storage and Rcesvery. ❑Salinity Hairier . ft, •• ft.
- CI Aquifer Test • f7Stonnw tterDr9ainagc R. ft: .
❑ xpciimctitiil Technology • .riSttbsidcncc Caniroi
-10 DRILLING'LOG Winch addiiionat.shects if necessary)
❑Geotitenntl(Closed Loop) ❑Tnicer FROM TO DeCRW ONfmbr.hnNncn.keWmckhpe riat.&A
❑Gtolltennal(Heating/Cooling,Return). . ❑0ther(explain under#21 Retnatksf o R. 15 11.. red fill
15 - ft. 35 • ft, silty sand red/tan .
4.Date WeEI(s)Canpleted: 5-24-23 yell II1t$tor-2D 35 ft. 62 ft, PWR with chunks of rock
;a.Well Location: 62 ft, 83 " tL bed rock e d
Winston Weaver Company ft. • ft. / `f,�re
Fact7ity,3wncrName Facility IDK(if applicable) f•t, ft. p •
4440 N. Cherry St., , Winston-Salem, NC, ,27105 • - R. ft. ttrA" ,. Pm." ,F. '
Physical Address City,and Zip- -a2t.REMARKS Llit
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Forsyth open hole screened from 73-83'
Cnut4y Parcel IdenlifeallonNo;(PIN)
h,lattitade and Longitude in dcgtscs/minutcs/seconds or decimal degrees:: 22-CertiCreatfon:
Of we ll(teed,or'Weftis stduelonl) -
• N • W ��'� • 5/29/2023
Sigmtusc of Certified Well Co for Daie
6.is(are)the weli(s): ZPermanent or ❑Temporary
11t'.signing whir farm,1 hercbt'certify Oaf 1hr ifr111s1 wax(were!constnrcrerl if accordancw.
with 1511 NCAC 02C.0100 or 15e1 NCAC 02C.0200 Well Coustmetion Starxianis,ntd dasher
7.Is this a repair to an existing well• Dyes or ®No .espy nj this recant has hs cn provided la the lsrll miter.
ifOa'La a repalr,fill au Alma well corasJrarcrloa hr/ormnrinu cad L;plolat the nature clew • -
repcir waster 121 rrrnarki•.ircrian or on rise brut of fhb:form: 23.Site diagram or additional Well details:
You may use the back of this page to'provide additional well site details or well
S.Number of Dells constructed: 1 • cot:steuction details. You may also attach additional pages if necessary.
For multiple hafeerinn or or vt-nnrer supply wells ONLY with the seine conslrurtlaur,Saar can
submit one farm. . 'SUBMITTAL,iNSTUCTIONS
9.Total well depot helow land surfaces 83 - (ff,) 24a.Far All Wells Submit this farm within 30 days of completion of bell
Far auahlple ire&list all eepths lldffl rsaus(example-3@20 W Will 2®100) construction to the following:
10.Static water level below top of easing: 24 -(I•) Division of Water Re.'iouices,lnfotmatiun Processing Unit,
Owlet'level is dare casing.lase"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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11,Boreholediamcter:12.25"/8"/6" (in,) 2-lb.For infection-Wells ONLY: iiaddition to.sending the form to the address in
24a above.also submit.a copy of this form within 30 days'of completion of well
12.Wcliconstructfau method:Auger/Air coaslmetiou to the following: -
(La.auger..rotary.cable.direct push.etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY:' i636 Mail Service Center,Raleigh,NC 27699-1636
83a Vied(gpm) Method of test: 24c.For Water Supply&Injection Wells: -
Also submit one copy of this fain within 30 days of completion of
1311.Disinfection type: Amount: well constnrction to the county health department of the count'where
• con-stdlcted. i ; •
Fanu GW-t Noah Carolina Dcprrnnaeni of Env remnant and Natural Resources-Division of WatcrRemtrtm Revised August 3ul3