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WELL CONSTRUCTION RECORD For Internal Use ONLY: 1
This form can be used for single or multiple wells
1.Well Contractor Information: ••••
CARL CARPENTER ia.WATER ZONES ,
FROM TO. - DESCRIPTION.
Well Contractor Name ft. ft. `
A - 4475 ft. ft. I i
NC Well Contractor Certification Number 15.OUTER CASING(for multi-casedwells)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* t0.0 ft. 2.0 in' 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 ft• 2.0 1n.' .010 SCH 40 PVC
ft. ft. in.(Heating/Cooling Supply) Residential Water Supply(sin le)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO, MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0.0 ft• S.0 ft. PORTLAND BENTONITE SLURRY
Non-Water Supply Well: ft. ft.
121Monitoring ORecovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable).
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery OSalinity Barrier
8.0 ft. 25.0 ft• 20-40 FINE SILICA SAND
❑Aquifer Test ❑Stormwater Drainage
ft. ft. .
0 Experimental Technology OSubsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Closed Loop) ❑Tracer 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 It ASPHALT/GRAVEL
11/02/21 MW-1 2.0 ft. 10.0 ft RED CLAY
4.Date Well(s)Completed: Well ID# 10.0 ft 20.0 ft• BROWN CLAY
Sa.Well Location: 20.0 ft. 25.0 ft. TAN SILTY SAAR 1 4 2022
ONE HOUR MARTINIZING ft. ft. f .,
Facility/Owner Name Facility ID#(if applicable) - -
ft. ft.
3520 YADKINVILLE ROAD WINSTON SALEM 27106 ft. ft.
Physical Address,City,and Zip
21.REMARKS
FORSYTH BENTONITE SEAL-5.0-8.0 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" W C - G`-.'„-sy 11/16/21
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or OTemporary By signing this form,/hereby certifr that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or IZINO 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-water supply wells ONLY with the same 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 if different(example-3@200'and 2 n 100) 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
j ,
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:
(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.Supnly&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 GW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013
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