GW1-2023-01393_Well Construction - GW1_20230208

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: -
1.Well Contractor Information:
RAWLINS CLARKE IV
_ i4aiwA<rERzoNEs �� *-
WellContractorName FROM TO DESCRIPTION
4234-A ft. ft. I i
ft. ft: � ,
NC Well Contractor Certification Number -
ISvOUTERGASING fartnulfi�cased wells 1?A-'LINER ifa"7icable',
Clarke Generations Drilling LLC FROM TO DIAMETER! THICI4YESS MATERIAL
ft. ft.
Company Name
UIC Permit WI400523 �16.F-1vEWCASINGOR:�rUSING''.�the;•iva,:eIosed-ldo VW
2,Well Construction Permit#: FROM TO DLAMETER' THICKNESS MATERIAL
List all applicable well constntction permits(i.e.UIC.County.State, Variance,etc.) ft. ft. ;• in,
3.Well Use(check well use): ft. ft. ,in.
Water Supply Well: ftVSCREEN:- :=,._
FROM TO DIAMETER 1' SLOT SIZE THICKNESS MATERIAL
Agricultural E)MunicipaVPublic ft.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
Industrial/Commercial ®I Residential Water Supply(shared) Iti18.`G ROUT''
71 Irrigation _ FROM TO }1 MATERIAL ~EMPLACEMENT METHOD Se AMOUNT
Non-Water Supply Well: ft. ft.
MonitoringE3Recovery ft. ft.
Injection Well: --
ft. et. l'
Aquifer Recharge groundwater Remediation- - ,_.,, .� F;,
+i19:SAND/GRAVEL''EACK'if a 'livable :::• _'' i t:,.r: b - z"''r-`
Aquifer Storage and Recovery Salinity Barrier FROM TO____L MATERLCL EMPLACEMENT METHOD
Aquifer Test Ostormwater Drainage ft. ft. !;
_ Experimental Technology Osubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer _ T20 DRILL L'IN -LOG attach:additioniil"shee&ifneceisa'-
FRO51 TO DESCRIPTION color,hardness,soil/rack a rain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) ft. ft. !
4.Date Well(s)Completed: 1/17/2023 Well ID#FS 207a ft. ft.
5a.Well Location: et. ft.
Salem Uniform Facility ft. ft. �'`� ' F in:i2.).
Facility/Owner Name Facility ID#(if applicable) ft. ft. '. 2023
4015 Cherry St, Winston Salem, NC 27105 ft. ft.
cg.�71 t'r:JG • .:,� �w
Physical Address,City,and Zip ft. ft. I, lIl?u;r"tl
21.°REMARKS-:
Forsyth County
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.Cer ation:
N W
1/25/2023
6.Is(are)the well(s)0Permanent or x(MTemporary Si re of Certified Well Contractor { Date
By signing this form, I hereby certify than the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or )No with 15A NCAC 02C.0100 or 0A NCACI02C.0200 Well Constntction 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 l GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:' I.
SUBMITTAL INSTRUCTIONS
I'
depth below land surface: 48
9.Total well de A)
p 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3L200'and-2@100') construction to the following:
f
10.Static water level below top of casing: n/a (ft.) Division of Water Resources,Information Processing Unit,
1f water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 1 5 (in.) 24b. For Infection Wells: In additil n!to sending the form to the address in 24a
direct push above, also submit one copy of this fo'Irtn within 30 days of completion of well
12.Well construction method: construction to the following:
e ,(t.' .auger,rotary,cable,direct push,etc.)
Division of Water Resources,U 1derground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Centtteir,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c. For Water SuuDly & Iniection Wells: In addition to sending the form to
the address(es) above, also submit lone 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. I i
f+ 1 G,,:,,,rw_t Nnrrh Cnrnlinn Denartment of Environmental Oualitv-Division of Water Resources I Revised 2-22-2016