GW1-2023-01394_Well Construction - GW1_20230208

WELL CONSTRUCTION RECORD (GW-1)- For Internal Use Only:
1.Well Contractor Information: -
RAWLINS CLARKE IV aL4t:wATER-ZONEs:::' - ,:. =
FROM TO DE r._ ....:.�.-.,__. ..,.. ..!.,:,,..a.-....., ,
Weil Contractor Name , SCRWTION
4234-A . ft. ft.
ft. ft. I _
NC Well Contractor Certification Number
45 OUTER'CASING for i l&:ised`:wells'OR'EINER if a"liable
Clarke Generations Drilling LLC FROM TO DIAMETERI THICKNESS MATERIAL
ft. ft. tin.
Company Name _ '
16rINNER°CASING:OR:TUBING' intheimahclosed-loo "> _
2.Well Construction Permit#: UIC Permit WI400523 FROM TO DIAMETER{ I THICKNESS 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. I' in.
Water Supply Well: i1758CREEN
FROM TO DIAMETER!' SLOT SIZE THICKNESS NATERIAL
Agricultural [3Municipal/Public ft. ft. in.j'
PGeothermal(Heating/Cooling Supply) ®IResidential Water Supply(single) ft. ft. in..
Industrial/Commercial [)Residential Water Supply(shared) 'iS: =' '?_ `:' : '....
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD g AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring I�l2ecovery ft. ft.
Injection Well: -
ft. ft.
Aquifer Recharge x)Groundwater Remediation
,19.
-SAND/GRAVEL*,PACK(ifapoli6ble =
Aquifer Storage and Recovery [3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ®IStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) DTracer 20:DRILI ING'LOG attach'additiaual sheets if necessa
FROM TO DESCRIPTION color,hardness,soiUrock e, min size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed: 1/19/2023 quell ID#FS 206b ft. rt.
5a.Well Location: - ft. ft. j
Salem Uniform Facility fr. ft.
..�
Facility/Owner Name Facility IDS(if applicable) ft. ft. L g L�1--g V U,
4015 Cherry St, Winston Salem, NC 27105 ft. ft. j r_co
Physical Address,City,and Zip
Forsyth County `-,21:REMARKS-­_ Ira
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 fication:
N W I' 1/25/2023
6.Is(are)the well(s)oPermanent or xOTemporary Si&6turJ 61 Certified Well Contractor 1. Date
By signing this form. I hereby certify thart the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E)Yes or xlMNo with 15A NCAC 02C.0100 or l.iA NCAC A2C.0200;Veil 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 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 I1I'
9.Total well depth below land surface: 31 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(ex'ample-3@200'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 Cente+,Raleigh,NC 27699-1617
11.Borehole diameter: 1.5 (in.) 24b.For Iniection Wells: In addition Ito sending the form to the address in 24a
direct push above, also submit one copy of this Jfomt 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 Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Centel,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c..For Water Suonly & Iniectio!.Wells: In addition to sending the form to
the address(es) above, also submit one 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