GW1-2022-07691_Well Construction - GW1_20220818

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID HALL 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name p
_ ft. ft. f
A - 4459 - 5� Cr
rt. ft.
NC Well Contractor Certification Number Fe 1` I v
E
15.OUTER CASING for multi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION AUK ! S 2�2� FROM TO DIAMETER THICKNESS MATERIAL
ft.
ft.
in.
Company Name fg URd 16.INNER CASING OR TUBING(geothermal closed-loop)
1{tiCifrs3.t 1�. ^T FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: QW;1i710G
List all applicable well construction permits(i.e.UIC,County,Slate-,variance,etc.) 0.0 ft. 23.0 It- 2.0 in. SCH 40 PVC
3.Well Use(check well use): ft. D. in.
Water Supply Well: 17.SCREEN
pPy FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 23.0 R. 38.0 ft' 2.0 in.
.010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
Olndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑We]Is>100,000 GPD FROM TO MATERIALMATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft• 18.0 ft- PORTLANDBENTONITE SLURRY
(MMonitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage 21.0 fr• 38.0 ft' 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) FROM TO DESCRIPTION color,hardness soil/rock e, rain size,etc.
)0.0 a• 38.0 ft' SILTY CLAY
4.Date Well(s)Completed: 07/25/22 Well ID# MW-25 rt. ft.
5a.Well Location:
AKZONOBEL
Facility/Owner Name Facility ID#(ifapplicable) ft.
3950 NEW WALKERTOWN ROAD WINSTON SALEM 27105 ft. fr.
Physical Address,City,and Zip ft. ft.
FORSYTH 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL- 18.0-21.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
360 08' 43.15" N 800 11' 17.86" W 08/16/22
6.Blare)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby ceriify that the well(.$)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or 15A NCAC.'02C.0200 Well Construction Standards and then a Copp
//'this is a repair,fill out known well construction information and explain the nature of the of dtis record has been provided io the well owner.
repair under#21 remarks section or on the back of7his form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 38'0
Por multiple wells list all depths ifdifjereni(example-3 200'and 1 r@r/00') Submit this GW-I within 30 days Of well completion per the following:
30.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft') Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lf.water level is above casing,use
11.Borehole diameter: 8.0 (in.) 24b. For Injection Wells: Copyjto,DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER
24c.For Water Supply and Opc"n-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells Producinlg over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1 61 1
13a.Yield(gpm) Method of test:
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13b.Disinfection type: Amount: l
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018