GW1-2023-01389_Well Construction - GW1_20230208

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: i
1.Well Contractor Information:
RAWLINS CLARKE IV i4wnTER=zoNEs . rt-'.' -Well Contractor Name FROM I TO I DESCRIPTION
4234-A ft. ft.
ft. ft.
NC Well Contractor Certification Number _
£15 OUTERCASING.for multi=cased wells OR-L-INER if a Hcable=-
Clarke Generations Drilling LLC FROM TO ohl-A— ER- THICKNESS MATERIAL
ft. ft. (i in.
Company Name
UIC Permit WI400523 ;=16:INNER CASING ORTQBING eothermalclosed-loo
2.Well Construction Permit#: FROM TO DfMETER THICKNESS I 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: �_17.�SCREEN�':=:'��:;.;.-. ;::;-.�.:=.�J�::::--_=.._-,:':.=:'.:,....,':_�=,,:r:;'.•.:�.: :, s:_:°:=
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) „' GROUT=, '?,
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge 00roundwater Remediation
19::SAND/GRAVEL PACK if a livable'-.-:-: -
Aquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD'
Aquifer Test ®IStormwater Drainage ft. It.
Experimental Technology OSubsidence Control ft. ft. i
Geothermal(Closed Loop) OlTracer 20;�'DRILL-ING.LOG-attach-idditi6i iI sheets if necessary) ".:
FROM TO DESCRIPTION color,hardness,soillrock .e, rain size,etc.) .
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed: 1/13/2023 well ID#FS 201 b ft. ft.
ft. ft.
5a.Well Location:
Salem Uniform Facility et. ft. y
Facility/Owner Name Facility iD#(if applicable)
4015 Cherry St, Winston Salem, NC 27105 ft. ft. FEB 0 Q 707.9
Physical Address,City,and Zip ft. ft.
Forsyth County _ 21_REMARKS- -
. i �l dd: •U:JU
County _... Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 2 ification:
N _ W 1/25/2023
6.Is(are)the well(s)oPermanent or lTemporary mre 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: E)Yes or xMNo with 15A NCAC 02C.0100 or I SA NCAC 02C.0200]fell 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.
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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS I:
9.Total well depth below land surface: 41 (ft-) 24a. For All Wells: Submit this' form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2 a 100') construction to the following:
10.Static water level below top of casing: n/e (ft.) Division of Water Resou'rees,Information Processing Unit,
1f water level is above casing,use"+" 1617 Nlail Service Clenter,Raleigh,NC 27699-1617
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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: 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 Cleniter,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c. For Water Suably & IniectionI 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. 1
Fnrm C W-I North Carolina Department of Environmental Quality-Division of Water Resourcesl I Revised 2-22-2016