GW1-2023-01384_Well Construction - GW1_20230208

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
I
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RAWLINS CLARKE IV
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Well Contractor Name FROM ft. TO DESCRIPTION
' ft.
4234-A I
ft. ft.
NC Well Contractor Certification Number I5 01)TER`EASING for multi-cased-wells'OR LINER'if ii eabll
Clarke Generations Drilling LLC FROM TO DIAMETER' THICKNESS MATERIAL
ft. ft. � I in, '
Company Name 4: .: ";'v.;•°,.-:.,.
UIC Permit W1400523 Z,16°-.HiNEWCASING.:0111 [JBING' iothii�mi1114iiied46 `<���:r='--::>s- ^�-- L
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County.State.Variance•etc.) ft. ft.
3.Well Use(check well use): ft. ft. in.
Water Supply Well r?1VSCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft. in,
Geothermal(Heating/Cooling Supply) ®IResidential-Water Supply(single) ft. ft. in:
Industrial/Commercial . [DResidential Water Supply(shared)
Irrl ation _ FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge -Ix Groundwater Remediation
.._.,.-
P,•19.,SAND/GRAVEt.PACK'ifa licable: __:,:'_ .:�:=::;:.:�;�r�,:•_-,ps-.-�•:k�--::�:::;-•r,,,....,
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer `t20sDRII1ING=LOG atfachadditional'stieetsifnecussa
FROM TO DESCRIPTION color,hardness,soiltrock e, rain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed: 1/12/2023 Well ID#FS 203b ft. ft. 11
5a.Well Location:
Salem Uniform_ Facility ft. ft. :�;�y�_ _ 4 -•
Facility/Owner Name Facility ID#(if applicable) ft. ft.
4015 Cherry St, Winston Salem, NC 27105 ft. ft.
Physical Address,City,and Zip ft. ft. i Unil
Forsyth County -•21.-REA ARKS
County--.-.. - - --- --- --- - --ParceLIdentification No.-(PIN) .
I
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22. ification:
N W
1/25/2023
6.Is(are)the well(s)0Permanent or xOTemporary gnu e o Certified WeII ontractor i Date
By signing this form,f hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or X)No with i5A NCAC 02C.0100 or i5A NCAC 02C.0200 Well Construction Standards 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. i
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 details. You may alsoi"attach additional pages if necessary.
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells
drilled:-'- SUBMITTAL INSTRUCTIONS 1I;
9.Total well depth below land surface: 24 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3C200'and 2 a 1001 construction to the following:
10.Static water level below top of casing: n/8 (ft.) Division of Water Resources,Information Processing Unit,
!/'water level is above casing,use"+' 1617 Mail Service Center,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
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: direct push 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 Tenter,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c. For Water Supply & iniectio I 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.
xi—h f—linn Ilennrtment of Fnvirnnmental(duality-Division Of Water Resources Revised 2-22-2016