GW1-2023-01386_Well Construction - GW1_20230208

iI
WELL CONSTRUCTION RECORD-fGW-1) For Internal Use Only:
1.Well Contractor Information:
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RAWLINS CLARKE IV AUWATEXIONES: -
Well Contractor Name FROM TO DESCRIPTION
4234-A ft. ft.
ft. ft.
NC Well Contractor Certification Number ,4�,lS=0UTERCASING fotmt d;tasediWM OR-
Clarke Generations Drilling LLC FROM To DIAMETER THICKNESS MATERIAL
- ft. ft. �' !in.Company Name -
UIC Permit WI400523 sd6VNERCASINGORTUBING eutbermalclosed=loti`
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS M MATERIAL
List all applicable well constndction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft. in:
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in:
Industrial/Commercial ®IResidential Water Supply(shared) .18.GROUT
Irrl ation FROM TO MATERIAL _v EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. Ft.
Monitoring ORecovery ft. ft.
Injection Well: - -
ft. ft.
Aquifer Recharge xlOGroundwater Remediation _
tiA%SAND/GRAVEUPAt K:ifa -liable'.-::-'.,,.::=.-:=.:.,-.:
_Aquifer Storage and Recovery _Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology DSubsidence Control
Geothermal(Closed Loop) ©ITracer _ - 20:DRIL'LING-LOG attach additional sheets if
FROM TO DESCRIPTION color,hardness,soiUrock 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 202C ft. R. h
5a.Well Location: ft. ft.
Salem Uniform Facility ft. ft.
Y ( PP ) ft. ft. tb J 2023
Facility/Owner/Owner Name Facility ID# if a liable )t
4015 Cherry St, Winston Salem, NC 27105 ft. ft.
Physical Address,City,and Zip ft. ft.
Forsyth County 21.REMARKS
County- _. __._ . Parcel Identification No.(PIN)-
5b.-Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,-one lat/long is sufficient) 22.Certification:
N W
- 1/25/2023 - -
6.Is(are)the well(s)0Permanent or xOTemporary
ature of Certified Well Contractor i Date
By signing this'orar, I hereby certify that the well(s)was(were)constntcted in accordance
7.Is this a repair to an existing well Yes or IX No with 15A NCAC 02C.0100 or 13A NCAC 02C.0200 PFell Consinrction Standards and that a
/'this is a repair,fill out known well constntction 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also lAttach additional pages if necessary.
drilled:' SUBMITTAL INSTRUCTIONS '
9.Total well depth below land surface: 28 (ft•) 24a. For All Wells: Submit thisl'form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following: �!
10.Static water level below top of casing: n/a (ft.) Division of Water Resources,Information Processing Unit,
ffwater level is above casing,use"+•• 1617 Mail Service Clenter,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 push above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following: C
(i.e.auger,rotary,cable,direct push,etc.) 1
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Nlethod of test: 24c. For Water SUDDIV & lnieeti I 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 the 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