GW1-2023-01392_Well Construction - GW1_20230208

WELL CONSTRUCTION-RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
RAWLINS CLARKE IV
Well Contractor Name FROM To DESCRIPTION
4234-A ft. ft.
NC Well Contractor Certification Number
5:15i0UTER CASING foe in ff-cased wells'OR
-tirel Clarke Generations Drilling LLC DIAMETER Ma liab
le
ft. 1 in.
Company Name ! I I
UIC Permit W1400523 M&R*WX'C-AS1NG OR:-- ING(i&thirnfid
•
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I mATERLAL
List all applicable well construction permits(i.e.UIC,County,State.Variance,etc.) ft. ft. j in.
3.Well Use(check well use): ft. fit. in.
=7
Water Supply Well: '!i'47.SCREEW
FROM TO DIAMETERSI SLOT SIZE THICKNESS I NfATEML
Agricultural OMunicipaVPublic ft. ft. in.1
i I
Geothermal(Heating/Cooling Supply) [3Residential Water Supply(single) ft. ft. in.1,
Industrial/Commercial Residential Water Supply(shared) jAK-GROUT
Irriaation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge OGroundwater Remediation - -4,
19.�,SAND/GRAVEL PACAC (if applicable)
nAquifer Storage and Recovery [3Salinity Barrier FROM TQ MATERIAL EMPLACEMENT METHOD
DAquifer Test [3Stormwater Drainage ft. ft.
N-
9—I.Experimental Technology Subsidence
Control
Geothermal(Closed Loop) [3Tracer t10..'DRILLING LOG(attach additional sheets if neiessary),.,.,
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)Geothermal(Heating/Cooling Return) MOther(explain Under#21 Remarks) ft. ft.
4.Date Well(s)Completed. 1/17/2023 Well IDft FS 207b ft. ft.
5a.Well Location: ft. ft.
%
Salem Uniform Facility ft. ft. a �5 4—Z
Facility/Owner Name Facility ID9(if applicable) ft. fit. I FEB 0 8'2023
4015 Cherry St, Winston Salem, NC 27105 -ft. ft.
ir
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:
(if well field,one lat/long is sufficient) 22 C 'fleation:
N W ;�g CAE< 1 1/25/2023
6.Is(are)the welf(s)oPermanent or OTemporary Signature of Certified Well Con or 1 Date
By signing this form,I hereby certift that he well(s)was(were)consinteted in accordance
7.Is this a repair to an existing well: []Yes or fix No with 15A iVCAC 02C.0100 or 114 NCAC 0,2C.0200 Well Constniction Standards and that a
9'this is a repair,fill out known well constriction information anti explain the nature qfthe copy of this record has been provided to the',well owner.
repair tender=2/remarks section or on the back of this fibrin. 23.Site diagram or additional well 1.details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to I provide 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:1 11
SUBMITTAL INSTRUCTIONS 1
9.Total well depth below land surface: 32 24a. For All Wells: Submit this fo tm within 30 days of completion of well
Formiduple wells list all depths if different(example-3@200'and 2@100') construction to the followin-
n/a
10.Static water level below top of casing: Division of Water Resources,Information Processing Unit,
If water level is above casing.use 1617 Mail Service Center;Raleigh,NC 27699-1617
11.Borehole diameter: 1.5
(in.) 24b. For Iniection Wells: In additio'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.)
Division of Water Resources,Underground Injection Control Pro-ram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,'Raleigh,NC 27699-1636
13a.Yield(opm) Niethod of test: 24c. For Water Su[)I)iv & lueection 1,1(i
11s: In addition to sending the form to
the address(es) above, also submit ohei 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