GW1-2022-07693_Well Construction - GW1_20220818

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information:
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NICHOLAS HAYES ;14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
� �� pd^ (! ft. ft.
A - 4121 9 m _9 � - ft. fr.
NC Well Contractor Certification Number n 15.OUTER CASING for multi-cased wells), LINER if a' ticable
GEOLOGIC EXPLORATION p.UG 2l'�� FROM TO DIAMETER TIDCKNESS MATERIAL
ft. in.
�. w Ftl :FROM TO DIAMETER ft.
Company Name
,16:INNER CASING OR TUBING "eothermal closed-too' " --
2.Well Construction Permit#: Ot•X � ER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 ft' 28.0 ft- 2.0 1°' SCH 40 PVC
3.Well Use(check well use): ft. ft. in-
REE
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 28.0 It' 38.0 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) 98.GROUT
❑Irrl ation ❑Wells>IOOOOOGPD FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 22.0 ft' PORTLAND;BENTONITE SLURRY
OMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation
19r SAND/GRAVEL:PAC K if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM 1 TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 27.0 ft- 38.0 ft- 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach"additioliafsheeaif:necEssn
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM I TO DESCRIPTION color,hardness,soil/mck type,Lrmin size,etc.
0.0 It- 4.0 ft• RED CLAY
4.Date Well(s)Completed: 06/16/22 Well ID# MW-3 4.0 n- 17.0 ft' BROWN SILT
5a.Well Location: 17.0 It- 27.0 rt' PWR
QUALITY PLUS 27.0 It- 38.0 ft• ROCK
Facility/Owner Name Facility ID#(if applicable) ft. ft.
2265 OLD SALISBURY ROAD WINSTON SALEM 27127 ft. ft. I
Physical Address,City,and Zip ft. ft.
FO RSYT H 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-22.0-27.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
360 02' 16.27" N 800 16' 19.56" W ��Ar� 06/17/22
6.Is(are)the well(s): 05Permanent or ❑Temporary Signature of Certified Well Contactor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance will?
7.Is this a repair to an existing well: ❑Yes or INNo 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known,veil construction information and explain the nature of the of this record has been provided to the well owner.
repair under 921 remarks section or on the back ofthis farm.
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-1 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 (It.)
Ear multiple wells list all depths ifeli ferent(example-3(200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 29.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+" Information Processing Unit,16171MSC,Raleigh,NC 27699-1617
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11.Borehole diameter: 6.0 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC27699-1636
12.Well construction method: AIR
24c.For Water Supply and Oper-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 producin¢over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh;NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018