GW1-2023-01390_Well Construction - GW1_20230208

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
RAWLINS CLARKE IV _, ._
v I4:WATER10NES r' t'�<::
Well Contractor Name FROM TO DESCRIPTION
4234-A
ft. ft.
NC Well Contractor Certification Number
145:,'0lJER-CASING`fodmal&c ed`weM•OR-L-INER Ufa licsble =
Clarke Generations Drilling LLC FROM TO DIAMETER THICKNESS MATERIAL
- ft, ft. I y.in.
Company Name
UIC Permit WI400523 '16.,NMXCASINGOR.TUBING eother&al!cl6ed400
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County.State, Variance,etc.) ft. ft. j in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: '=17:SCREEN..;: ; a;.;:. =r:f. t;:,•:r.c,;.:: = i.::..^:". .-:.
FROM TO DIAMETER' I SLOTSIZE THICKNESS MATERIAL
Agricultural [DMunicipaVPublic ft. ft. in.!,
Geothermal(Heating/Cooling Supply) ©IResidential Water Supply(single) ft. ft.
Industrial/Commercial [3Residential Water Supply(shared)
18.GROITf
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge oGroundwater Remediation
19.$AND/GRAVEL PACK if a licable
Aquifer Storage and Recovery Salinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
PExperimental Technology OSubsidence Control ft. ft. !
Geothermal(Closed Loop) ®ITracer _ i-20.DRILLING:LOG attach additional sheets ifnecessa '
Geothermal(Heating/Cooling Return)- 00ther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.)
ft. ft.
4.Date Well(s)Completed: 1/17/2023 Well ID#FS 208b ft. ft.
Sa.Well Location: - ft, ft.
Salem Uniform Facility ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. F t
4015 Cherry.St, Winston Salem, NC 27105 ft. ft.
_ t,
Physical Address,City,and Zip
Forsyth County- :21.-REnzARKS !. _
County. _ _ _ Parcel Identification No.(PIN)
i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22. er fieation:
N WK, 1/25/2023
6.Is(are)the well(s)oPermanent or xOTemporary SiNditurd of Certified-W -n c or i; 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 15A NCAC 02C.0100 or I SA NCAC 02C.0200 Well Construction Standards and that a
!f 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•fora.
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 tolprovide additional well site details or well
construction,only I GW-I 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: 31 (ft•) 24a. For All Wells: Submit this fol,within 30 days of completion of well
For multiple wells list all depths fftliferew(example-3@200'and 2 a 100') construction to the following:
10.Static water level below top of casing: Na Division of Water Resources,information Processing Unit,
If water level is above casing,use„+'• 1617 Mail Service Cente'r,IRaleigh,NC 27699-1617
11.Borehole diameter: 1.5 (in.) 24b. For Iniection 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:
(i.e.auger, cable,direct push,etc.) I
i g ,rot ,
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 & Iniection Wells: In addition to sending the form to
the address(es) above, also submit one !copy of this form within 30 days of
t3b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016