GW1-2023-01385_Well Construction - GW1_20230208

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
RAWLINS CLARKE IV �^
.T4z.+
WATER2ONES"::-,`' .<::=::''.;:):::i,:-.<�•..-_=::=:;-.`'-<�;�5;3:=:i;�.z•��•.,:�-=;...;=.:
Well Contractor Name FROM TO DESCRIPTION
4234-A ft. ft.
ft.
NC Well Contractor Certification Number th
.15::0UTER CASING(floe' cased wells'OR LINER if e-'licable
Clarke Generations Drilling LLC FROM TO DIAMETER THICKNESS MATERIA
ft. ft. I io. -
Company Name
UIC Permit WI400523 h16 1NNER,CASING-ORTusING. d6sed4dopJ
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits�.e.UIC,County,State.Variance.etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: E:17i,'SCREEN,'',-- ,.. :_:,_ `,::::.. , a-;., :•..__. :_._.:: _, : _
FROM TO DIAMETER, SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft. in',
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in•'
Industrial/Commercial Residential Water Supply(shared) _
IrTI ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge xl ]Groundwater Remediation
i119.SAND/GRAVEL-PACK if a licable.
Aquifer Storage and Recovery [3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft. j
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer ,i20.DRILLING LOG.attach additibual'sheets if necessary)'.
FROM TO DESCRIPTION(color,hardness,soiVrock e, rain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM
ft.
4.Date Well(s)Completed: 1/12/2023 Well ID#FS 203a ft. ft. i!
Sa.Well Location: ft. ft.
ft. ft.
Salem Uniform Facility _
Facility/Owner Name Facility ID#(if applicable) ft. ft. 8 2023
4015 Cherry St, Winston Salem, NC 27105 fr. rr. IntaJr r xi"I �r „ ,
Physical Address,City,and Zip
ft. et'b`od
Forsyth County ?121.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.Certification:
N - W its , 1/25/2023
6.Is(are)the weil(s)oPermanent or xOTemporary • atu a ofCertified We ontractor i' Date
By signing this form,I hereby certify thi t the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E)Yes or E)No with 15A NCAC 02C.0100 or ISA 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.
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repair under=2I remarks section or on the back of this form. Il
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 pagei to.provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:' SUBMITTAL INSTRUCTIONS �
9.Total well depth below land surface: 42 (ft-) 24a. For All Wells: Submit this"form within 30 days of completion of well
For multiple wells list all depths if different(erample-.3@200'and 3 a I00') construction to the following:
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 Center,Raleigh,NC 27699-1617
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it.Borehole diameter: 1 5 (in.) 24b. For Infection Wells: In addition to sending the form to the address in 24a
direct push above, also submit one copy of this form 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 Cen:er,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c. For Water Sunaly & Iniectil n 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 ttie county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016