GW1--04715_Well Construction - GW1_20230721

WELL CONSTRUCTION RECORD For tntenul Use ONLY:
This form can be used for single or untitipk wells•
1.Wdl.Contractor Information: •
1 I..WATER,ZONES
Scott Hunt, Jr roost • TO DESCRIPTION
Well Contractor Name • • 87 ft. ft. rock 'fracture
4561-A ft, ft. I
NC Well CamractorCaniftcirlioit NumberIS.OUTER CASING(foratulli:(aacd a'elisl OR LiINER(if au tk:tbte)
FROM TO, DIAatETER THICKNESS MATERIAL
SAEDACCO Inc •
0 ft. 80 ft, 6 . in. SCH-40 .• Carbon Steel
Cainputy Naam Id:INNER CASING ORTTUBINt3(yeaihermal closed-loop) ' .
WHOM • TO • DI.MiETER THICKNESS MATERIAL
2.Welt Construction Permit 8: • -R, ft. 'in.
List aft atplicable well permits(i e.County.Stale.Variance.frOctian etc.)
R. . ft. in.
3.Wall Use(ettccicwdl use); II:SCREEN
•
Water Supply well: - FROM TO DIAMETER sr,OTSIM TiIICKNFSS SIATRRIAi.
❑Agtirilltiurml • .❑MuntcipaliPublic 80 ri. 90 R. 6 in NA NA NA
•
CIGeothelr al(Iiieating1Cooliog Supply) ®Residential Water Supply(single) R. IL .in.
®indusuiallconunercial DResiilcntial Water Supply(shared) t8:GttOUi ... - , -
mom' TO MATERIAL 7 EMPLACEMOIT METHOD&AMOUNT
. Dissipation . 0 ft. 80 . ft. Portland Tremie
Non-Water Supply Well: • tt, rt. .
Monitoring I:Recover)' . .
• Injection Well: - rt. ft,'
•
❑AgnifcrRecharge DGroundli:ftcrRentcdiation - 19:SANDIGRAVEL PACK(if arrplit bteY
'WHOM ' TO SIATE.RIAI. R\IPI.A(i ENT METRO
. ❑Agnrll r Storage and Rectwery OSalinity 13amcr R. ft. .
❑Aquifer test ❑Stommatcrl}retnago Liz ft.
❑E gscamcntal Tochnoto ' 05tthsidence Control..
• "Ie DRILLING'LOG(attach additional.Aver s if neccssarvl
❑Geotltemral(Closed Loop) ❑Trtcer FROM . 74 DESCRIPTION(color.hardrien.tolPrmkhpt.irrein Arr.dr.)'
❑Geotltential(Heating/Cooling Return), , ❑Other( rlaitt under 821 Retuatksl ' 0 ft, is tt. red fill
15 fL 40 ft, silty sand red/tan '
4.Date Well(s)Completed: 5-19-23 Well iD#mt'1-1D. • . - .
40 ft.. 70 -.ft. PWR with chunks roof rock
Sa.1Vel1 Location; 70 ft. 90 ft, bedrock r
•
1 h '
Winston Weaver Company ' . ft.: ' ft.
r . a �
Factlit)•,'OwhcrName Facility IDII(ifappiieable) _._ _ - - - -
R. R. Jr. r 1 2023
4440 N. Cherry St. , Winston-Salem, NC, 27105 R.. rt.
Ph sisal Address iriorit:arlpn p.n.
City.and Zip 2L REMARKS V Ur
Forsyth ' open hole screened from 80-90' . ` uZ , -
County Parcel Idi.ulilleation No,(PIN)
SI,,Latitude and longitude in'degr ecsiminutcslscennds or d'ccitnal degrccs: 22:Certification:
On ell field,one IaU1oug Is'sufflelent)
- N • W` c5)Cia #61.42 5/29/2023
SigtularaufCeitifiedWellCom tar Datc
6.Is(are)lbe:R'dl(s)t ZiPerlitanettl or ❑Temporal}'. ii nln this unre,!hereby err!! Thar t r Yrrll s was em! mai:rucind in accordance
4. s b f f> r!
with(St MC 02C,0103 or 1S4 NOW 62C.02MT Wet!Conitrrertou Standards and that a
7.isthisa repair tit an existing wdl: DYm or BIND copy of Mir mcord'hos ken provided roMeinliowner.
' If this is o repair,full no kpoesr well ceosrnrertoa lrrforrnerlon oral tApla1n the lkitrire of rite -
repair under 621 re:nants arciian ar on.the Mack ofthri form ' - 23.Site diagram or additional well details:
You may use the back of this page to provide additional-wehl site details or Well •
8.Number of wells constntctecl: 1 • .. construction details. You may also attach additional pages if necessary.
For multiple(tferrlott'or rtrur-rvare•r sum*wells ONLY is i h;helmet eotrsrruelfon.I top can
rn sabinir one for . ' SUBMITTAL iNSTUCTiONS
. 9.Total well depth below.land surface. - 90 ' (D.) 24a..For All Wens:, Subntit this for::within 30 days of Completion of welt
Forrealriptewellslistrrlldephsifditi!rrnr(e-vrropla•-3@201t'orul201(11ty construction to the following: .
10.Static water level below top of casing: 22 . . (IL) Division of Water Resources,Inforviatioti Prueessing Unit,
!f Writer level is dove nrstox use"+" 1617 Marl Service Center,Raleigh,NC 27699-1617
Ii,Borehole diameter.12.25_"/e"/6" - (in.) 24h.For tit tecdorkWSllIONLY: in addition to.sending the form to the address in
24a above.also submit a copy of this fonts within 30 days of completion of well
112.Well construction method:Auger/Air construction to the following: ,
(Lc.auger..ratasy.cable din cl Disk etc.) I I
Division of Water Resources,Underground Injection Control Progrutn,
. FOR WATER SUPPLY WELLS ONLY: 1636 Masi Service Cenfcr,Raleigh,NC 27699-1636 •
I3a.Kidd(gpm) ,Method of test: ?le.For Watcc-Sapply&'Injection Wells:
Also submit one copy of this feint•within 30 days of completion of
13h.Disinfection ty ne: Amount: well construction to the county health I
department of the county where;
constructed.
Fonts GW-t North Carolina Department of Eswironnrern and Natural Resources—Division of Water Reams Revised Augtst MU