GW1-2022-07692_Well Construction - GW1_20220818

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
NICHOLAS HAYES 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
ft. ft. P
A - 4121 �, ft. f
NC Well Contractor Certification Number R l�.C _y �� E 15.OUTErr.R CASING for ivalti cased Its OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
+ ft. ft. in.
Company Name '
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: ''r., '3;rnvish'.'l i. • Unit FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits r.e.U1C, ounty,SfolV aI&S,(i)G 0.0 ft. 20.0 ft. 2.0 ' in. SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 20.0 f" 30.0 ft. 2.0 in'. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑bTl ation ❑Wells>100000GPD FROM TO MATERIAL EMPLACEMENTMETHOD&AMOl1NT
Non-Water Supply Well: 0.0 ft. 13.0 ft' PORTLANDBENTONRE SLURRY
I!flMonitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 18.0 ft. 30.0 ft. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if Hares"sa' "
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soil/rock a rain size etc.
0.0 ft. 4.0 ft. RED CLAY
4.Date Well(s)Completed: 06/16/22 Well ID# MW-4 4.0 ft. 15.0 ft. BROWN SILT
Sa.Well Location: 15.0 ft. 17.0 n' WHITE ROCK
QUALITY PLUS 17.0 ft. 23.0 ft. PWR/ROCK
Facility/OwnerNan;e Facility 1139(if applicable) 23.0 ft. 1 26.0 ft- WEATHERED ROCK
2265 OLD SALISBURY ROAD WINSTON SALEM 27127 26.0 ft- 30.0 ft. ROCK
Physical Address,City,and Zip ft. ft.
FO RSYTH 21.REMARKS
County Parcel Identification No.(PIN) BENTONIfE SEAL- 13.0-18.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
360 02' 15.92" N 800 16' 19.91" W 06/17/22
6.Is(are)the well(s): INPermanent or ❑Temporary Signature ofCerfified well Contractor Date
By signing this form,/hereby certify that the well(s)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 that a copy
1f this is a repair,fill out known well construction information and explain the nature of the ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis 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 1 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: 30.0 (ft.)
For multiple wells list all depths ifdii ferent(example-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
23.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,16171MSC,Raleigh,NC 27699-1617
1f water level is above casing,use•'+"
11.Borehole diameter: 6.0 (in.) 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR
24c.For Water Supply and Open i-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 producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh;NC 27699-1611
13b.Disinfection type: Amount:
l
Fonn GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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