GW1-2023-01382_Well Construction - GW1_20230208

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
RAWLINS CLARKE IV
ri3ra wnTER�zorrEs;;,:•- -= I:.t.- -Well Contractor Name FROM TO DESCRIPTION
4234-A ft• ft.
ft. ft. f
NC Well Contractor Certification Number
i>15 r-0UTER,CASING foe alti cased wells'OR-LINER-ifa 'Gable
Clarke Generations Drilling LLC FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. i I in.
Company Name _ ._
UIC Permit W1400523 116.,1E4NER'CA3INGOR=ING:(dothermal.closed-loo' <:' ''
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits ri.e.UIC,County.State,Variance,etc.) +fftt
in.3.Well Use(check well use): ft. in.
Water Supply Well
FROM TO DLANIETER1, SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipaVPublic ft. ft.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft.
Industrial/Commercial 1DResidential Water Supply(shared) .a1s GROUT;,:: ;= :• =. ": :1••c'-' <=
Irrigation FROM TO MATERUL EMPLACEMENT METHOD&MOUNT
Non-Water Supply Well: ft. ft. ,
OM onitoring Dkecovery
Injection Well: - -
Aquifer Recharge xiOGroundwater Remediation ft. ft.
z`19.,SAND/GRAVEL'PACK ifa ..liable -
Aquifer Storage and Recovery ®3Salinity Barrier FROM TO MATERUL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft. C
Geothermal(Closed Loop) Tracer ,,20:DRMLING'LOG:attach addidonalsheets if necessa =
FROM TO DESCRIPTION color,hardness,soillrock e, rain size,etc.)
PGeothermal(Heating/Cooling Return) Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed: 1/18/2023 Well ID#FS 204b ft. ft.
5a.Well Location: ft. ft.
Salem Uniform Facility ft. rt. g .,MV�r"" ri
,
Facility/Owner Name Facility ID#(if applicable) fr. ft. I —
4015 Cherry St, Winston Salem, NC 27105 ft. ft. '
Physical Address,City,and Zip �, In —
Physical eTS.tvA t rc y-W'.0 hn.i
Forsyth County ,"21.REMARKS
County __ _ _______. _ _ _._-Parcel.identification-No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22, er fteation•
N w1/25/2023
6.Is(are)the well(s)f3Permanent or x)Temporary matu a of 4emfied'we[T-ontracror Dace
By signing this form, I hereby certq�that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or EJNo with ISA NCAC 02C.0100 or IjA NCAC.02C.0200 Well Construction Standard[and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under=21 remarks section or on the back of this 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 site details or well
construction,only l GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also a ttach.additional pages if necessary.
drilled:' SUBLMITTAL INSTRUCTIONS j,
9.Total well depth below land surface: 28 (ft-) 24a. For All Wells: Submit this !form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3 a 100•and 2 tt 100') construction to the fol lowing: ,
10.Static water level below top of casing: n/a (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Centel
i
tr,Raleigh,NC 27699-1617
11.Borehole diameter: 1.5 (in.) 24b. For Infection Wells: In addition to sending the form to the address in 24a
direct h above, also submit one copy of this form rm within 30 days of completion of well
12.Well construction method: p construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service CelInter,Raleigh,-NC 27699-1636
13a.Yield(gpm) Method of test: 24c. For Water Sunoly & Iniection 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.
Fonn GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016