GW1--04714_Well Construction - GW1_20230721

• WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multipk wells•
I.WelL.Contrtctor information:
•Li.WATER ZONES
Scott Hunt, Jr rno'1 To DPSCRIPTn1N
wettCorllragorNark! 11 ft. 19 ft. silty sandy
4561-A ft. f.
NC Well ConuaciorCenifraation ThurbertS.OUTER CASING(for muhl-eaeciI dllsl OR-LINER of an fleabkl-
FnOS! TO • DIAMETER THICKNESS MATERIAL
SAEDACCO Inc f[. It isr
Comisuty Nance td.INNER CASING OR TUBING(Iteothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 9 ft, 2 in. SCH-40 PVC
fin all applicable wolf penults(Le.Counts.State,Variance.L.y"a ket elt)
. R. rt. -EFL,
3.Well Use(cheek well use): 17:SCRE N .
Water Supply Welt: FROM TO DIAMETER SLOT SIZE TntCKNFSS i MATRRIAI,
CIAgiteultutal DMunicipal/Public 9 if. 19 R. 2 ire O10 SCH-40 PVC
®Geothermal(EleatingiCooling Supply) ®Residential Water Supply(single) ft. R. in
❑lnduslriallConlnicrcial ' ©Residential Wafer Supply'(shared) ' oGRAI°IT TO TL4rERlAI. EMPLACEMENT METHOD SAMOUNT
• ❑knpation 0 ft. 5 ft. Portland Tremie
Nort:Water Supply Wolt:
ft. rt.
W Manitoring •.IJRccovcty , -
Injection Well: ft.• ft.
• °Aquifer Recharge °Groundwater.Rencdialion t9:SAND/GRAVEL PACK(if;ypdicabte)
FROM 10 MATRRIAl. EMPI ACEVENT AiFTUOI
GJAiplifcr Storage and Recovery f7Salinity Battier 7 ft. 19 ft. Sand #2
. . °Aquifer Test ❑Stormwatcr 13rainaae it. ft.
❑Experftnental Technology ❑Subsidence Control
2n:DRILLING LOG farlach addiiionalsbects If necessarvl
❑Geotitennal(Closed Loop) ❑Tr.icer FROM To DESCRIPTION(anbr.hardnea.willow&h6a sain.vaAe.t
❑Geothennal(IIeatinalCooliugReturn) . ❑Other(explain,under#2!Remads) o ft. 1 ft, fill
1 ft. 11 ft. silty clay
4.Date Wetl(s)ConipleIed: 5-18-23 -well 11 WMW-9
• 11 ft, 19 R. silty sand .
Sa.,Well Locatlrn: ft. ft.
Winston Weaver Company ft. ft.Faciility/OwncrNuna: Facility ID#(if applicable) •
R. It, m Jul 023
4440 N. Cherry St. , Winston-Salem, NC, 27105 ft. ft - h.or.�i•.r,.4u,�r,r�
ceigaria. link
Plrysi:al,Addiess,City.and Zip -21.RENIARKS M` "OG
Forsyth Bentonite seal from 5-7'
County Parcel Itkatificalion Ng,(PIN)
a1_r.I atiMde and Longitude in degrtes/minutcs/seeands or decimal degrees: 22.Cct'tifcatiiin:
(if moll field,one Iailloug is Sufllcienl) . . . .
N . W 3Co ant- 5/21/2023
Sigrutur ofCcitificd Well Cont or Dale
6.Is(are)the rvell(s): KIPennaneat or DTemporary. !h•signing rhts form,1 hereby eel-1y duff lire we'l(S)wax fm-n J cartxtnecleyl in aclordancr
with 15A NCAC 02C.0100 or 15A NCAC 02C,0200 nail Conslrsrclion Staridrrnis and char<r
7.Cs this a repair to an existing well; ❑Yew or El No. eefiy of rhir reconl has been pm urled to Or;urn-miter,
!f['Mir a reptilr,fill oar ktlfliV;1 well coo Inrcl(oo lirforrranrlaa errael exploht the Harare of the
repair wider1121 remarks srrle'an ar an the back of this form. 23.Site diagram or additional Well details:
• You may use the back of this page to provide additional-well site details.or welt
8.Number of wells constructed: 1 construction detaiis. You may also attach additional pages if necessary.
For ann11.0k Iojecrlon or non-aster supply'veils ONLY with the sarrk constrketIosr,}you can
satanic one form. SUBMITTAi.iNSTUCTIONS
9.Total well depth below.land surface. 19 (fe.) 24a. Fur Alt Wells Submit this farm within 30 days of completion of well
For multiple wells list off ATMs lfd1,@ircuitf<',1-<Toipfe-.r@200'and 20d(to') eonstmctiento the following:
E0.Static water level below top of easing: 11 (ff.) Division of Water Resources,Information Processing Unit,
if inter level is abuse castrag,use"4." 1617 Mail Service Center,Raleig t,NC 27699-1617
IL Borehole diarnctcr:8.25" (in.) tab.For tia,jeetlon'Wells ONLY: in addition to sending the form to the address in
24a above.also submit a copy of this foam within 30 days of completion of well
12.Well construction method:Auger construction to the following:
(i.c.mgr.ritually,cable din ct push c[c:} Division of Water Resources,Underground Injection Control Program,
' FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27689.1636
Il3ro Yield(gym) Method of test: toe.For Water Supply&Injection Welts:
Also submit one copy of this forum within 30 days of completion of
tivell constmction try the eatery Ii�alth department of the county where
Il3h.Disinfection type: Amount: 1
• constructed. 1 ,
Form GRr-1 North Carolina Department of Eunifonnmcru and Natural Resources-Division of Water Reatrc Revised August 2013