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WELL CONSTRUCTION RECORD For Internal Use ONLY: 1
This form can be used for single or multiple wells 1.
1.Well Contractor Information:
CARL CARPENTER 14.WATER ZONES
FROM TO DESCRIPTION.
Well Contractor Name ft. ft. I
A - 4475 ft. rt.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable) .
FROM TO DIAMETER THICKNESS MATERIAL.
GEOLOGIC EXPLORATION, INC ft. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM . TO DIAMETER. THICKNESS . MATERIAL
2.Well Construction Permit#: 0.0 ft' 10.0 it 2.0 I' SCH 40 _ PVC
List all applicable well construction permits(i.e.County,State,Variance,etc.) - •
ft. ft. in.
3.Well Use(check well use): 17.SCREEN, _
Water Supply Well: FROM. TO , DIAMETER SLOT SIZE THICKNESS MATERIAL
'Agricultural ❑Municipal/Public 10.0 ft' 25.0 ff 2.0 1n .010 SCH 40 PVC
ft. ft. in.
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(sin le)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM _ TO MATERIAL , EMPLACEMENT METHOD&AMOUNT
Olrrigation 0.0 ft. 5.0 ft. •PORTLANDtENTONITE SLURRY
Non-Water Supply Well:
ft. ft.
tZMonitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier R. ft.
8.0 25.0 20-40 FINE SILICA SAND
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary) .
OGeothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0.0 ft. 2.0 ft. ASPHALT/GRAVEL
11/01/21 MW-4 2.0 ft. 10.0 ft• RED CLAY
4.Date Well(s)Completed: Well ID#
10.0 ft' 20.0 ft' BROWN CLAY
5a.Well Location:
20.0 ft' 25.0 ft' TAN SILTY SAND -
ONE HOUR MARTINIZING ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. MAR 1 ,n,,
3520 YADKINVILLE ROAD WINSTON SALEM 27106 R. ft. 11I
Physical Address,City,and Zip 21.REMARKS
FORSYTH BENTONITE SEAL-'5.-8.0 FEET
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient) ,� '
36° 09' 09.94" N 80° 18' 47.42" �-�- 11/16/21
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or lNo copy of this record has been provided to the well owner.
If this is a repair,Jill out known well construction information and explain the nature of the
repair under#21 remarks section or on 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 well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-seater supply wells ONLY with the saute construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: • 25.0 (ft.) 24a. For All Wells: Submit this:form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Q200'and 2Q100) construction to the following:
10.Static water level below top of casing: 12.0 (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8'0 (in.) 24b. For Injection Wells: In addition to sending the form to the address in 24a
AUGER above, also submit a copy of this{form within 30 days of completion of well
12.Well construction method: construction to the following: fi h
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,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&Injection 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 G W-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013
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