GW1-2023-01387_Well Construction - GW1_20230208

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
RAWLINS CLARKE IV Vf4 WATE1UZONES,• Q; :r;=
Well Contractor Name FROM ft. TO ft. DESCRIPTION
l
4234-A
ft. ft.
NC Well Contractor Certification Number
15OUPERtCASING:Fonrnutti cased=wel4 URliINER.ife"Gcsibr
Clarke Generations Drilling LLC FROM I TO I DIAMETERI I THICKNESS MATERIAL
ft. ft. � in. -
Company Name f16:-VNER:CASMG OR TUBING` ii6thermal elosed l6o','-`;-�cq:?
2.Well Construction Permit#: U IC Permit WI4OO523 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well - rs17 SCREENY.� :.::;;;.,: aF, ; >; >~;. a.',. ,•,mot .e:r ;
FROM TO DIAMETER SLOT SiZE THICKNESS I MATERIAL
Agricultural OMunicipal/Public
Geothermal-(Heating/Cooling Supply) Residential Water Supply(single) ft. ft.
Industrial/Commercial [3Residential Water Supply(shared) 18:`GROUT° 3 - - == -;f, Y e•_;.: "°-T
Irrigation FROM hT0' - MATERIAL `EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
Monitoring 1311ecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge xl��Groundwater Remediation ,„_
V,19=SAND/GRAYELTIACK tfa licitble:
;.._,.
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer g20.�DRIL-LING-LOG attachadditioualaheetsifnecessa' �''-5, "A:'>>'` ��`•'- .
Geothermal(Heating/Cooling Return) 00ther(explain-under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiurock a rain size,etc.
ft. ft.
4.Date Well(s)Completed: 1/12/2023 Well ID#FS 202b ft. ft. rr
5a.Well Location:
Salem Uniform Facility ft. ft.
Facility/Owner Name Facility IDS(if applicable) ft. ft.
4015 Cherry St, Winston Salem, NC 27105 ft. ft.
Physical Address,City,and Zip ft. ft. ;'sVe1sr2i3CG
Forsyth County
,21:REtrtARxs -
r
County Parcel Identification No.(PIN) I'
5b.Latitude and-longitude in degrees/minutes/seconds or decimal degrees: +
(if well field,one]at/long is sufficient) 22.Certification:
N W 1/25/2023
" E
6.Is(are)the well(s)0Permanent or xOTemporary • ature of Certified Well Contractor Date
By signing this form, I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or E)No with LiA NCAC 02C.0100 or Ida 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 121 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 attach additional pages if necessary.
drilled:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 43 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(eromple-3C200'and 2@100') construction to the following: ,
10.Static water level below top of casing: n/a (ft.) Division of Water Resolrces,Information Processing Unit,
Ifwater level is above casing,use"+^ 1617 Nfail Service Center,Raleigh,NC 27699-1617
It.Borehole diameter: 1.5 m.
(• ) 24b. For[niection Wells: In additi In 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:
(i.e.auger,rotary,cable,direct push,etc.) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c. For Water Supply& Iniectton Wells: in addition to sending the form to
the address(es) above, also submit bne 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. fl
r�rt r,W_t North Carolina Department of Environmental Oualitv-Division of Water Resources) Revised 2-22-2016