GW1-2023-01388_Well Construction - GW1_20230208

i
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
1 I
RAWLINS CLARKE IV
Well Contractor Name FROM TO DESCRIPTION
4234-A ft. ft.
ft. ft.
NC Well Contractor Certification Number
IS OUTER':CASING fdr"ui6lti�cased wells'OR E INER'if a `liceble<<=
Clarke Generations Drilling LLC FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
U lrT6:e1NNERt CASING*OR-T[jBING' eothermel'clased=too _� -- . :=•--
2.Well Construction Permit# IC Permit WI400523 FROM TO DIAMETER THICKNESS MATE
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: 17rSCREEN.:. r;`iia::-;;'-.:.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERWL
Agricultural OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) -[3Residential Water Supply(single) ft.
Industrial/Commercial f3Residential Water Supply(shared)
Irrigation FROM TO MATERL►L EMPLACEMENT METHOD g AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge xOGroundwater Remediation
;.:.. :.
or19::SAND/GRAVEL'PACK ifa licable
Aquifer Storage and Recovery _DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Storrnwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
B
Geother (-_Geothermal(Closed Loop) Tracer DRILLING LOG:attach addifionalsheefs if necessa
Geothermal(Heating/Cooling Return) _ Other(explain under#21 Remarks) 'a:'.: =='•'•':
FROM TO DESCRIPTION color,hardness,soil/rock e, rain size,etc.)
ft. ft. ;'
4.Date Well(s)Completed: 1/12/2023 Well ID#FS 202a ft. ft.
5a.Well_Location: ft. ft.
Salem Uniform_Facility ft. ft. ;e ,C: V av L„x
Facility/Owner Name Facility ID#(if applicable) ft. ft. iFEB
' Q 2023
4015 Cherry St, Winston Salem, NC 27105 ft. ft.
Physical Address,City,and Zip ft. ft.
-Forsyth County `.21.REMARKS
County----- — Parcel Identification No.(P-IN). II
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Cc tcation:
N W1A h
1/25/2023
6.Is(are)the well(s)0Permanent or xOTemporary tgnature of Certified Well ractor Date
By signing this form.I hereby certify tharthe well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or E)No with/SA NCAC 02C.0100 or 15A 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;thd well owner.
repair tinder--21 remarks section or on the back of this form. i
23.Site diagram or additional we I l 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 also!attach additional pages if necessary.
construction,only I GW-I is needed. Indicate TOTAL NUMBEi7ofwells
drilled:-' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 55 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 a_'00'and 2@ 100') construction to the following:
10.Static water level below top of casing: Na (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
I
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 thiis 4form within 30 days of completion of well
12.Well construction method: construction to the following: f
(i.e.auger,rotary,cable,direct push,etc.)
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 & Iniectio I Wells: In addition to sending the form to
the address(es) above, also submit 'one copy of this forth within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
c—C,w-t North Carolina Denartment of Environmental Ouality-Division of Water Resources Revised 2-22-2016