GW1-2023-01397_Well Construction - GW1_20230208

WELL CONSTRUCTION RECORD (GW-j For Internal Use Only: i
1.Well Contractor Information:
RAWLINS CLARKE IV I
rL4:WATER=ZONES � >f���e��T•�
Well Contractor Name - FROM TO DESCRIPTION
4234-A rt. ft.
ft. ft. l
NC Well Contractor Certification Number
``ul5:'OUTER-CASING'formniti=ca W'wills_OR'LINER if a"li ''able
Clarke Generations Drilling LLC FROM TO DIAMETERI THICKNESS MATERIAL
ft. ft. I lio.
Company Name
UIC Permit W1400523 ?�16-MERCASINGORTUBING' iiithiimalchised=loo
2.Well Construction Permit#: FROM T TO DIAMETER' THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. I, ,in.
3.Well Use(check well use): ft. ft. I; in.
Wa ter Supply Well: - !-,47:SCREEN:._::p:=_._._FROM TO DIAMETER i SLOT SIZE THICKNESS MATERIAL
Agricultural - [)Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.i'
Industrial/Commercial -Residential Water Supply(shared) 4. 1
18r'GROUTi
Irrigation FROM TO NIATERL►L EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.'
Monitoring DRecovery ft. ft.
Injection-Well: - -
ft. ft.
Aquifer Recharge xEGroundwater Remediation
+ D/GRAVELPAK Iicable
Aquifer Storage and Recovery� 0Salini -Barrier FROM TO MATERL\L • • ` '
_ _ � EMPLACEMENT METHOD
Aquifer Test ®IStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) ®ITracer ;20:DRILLING'LOG'atfaiti additional'sheets if necessa
FROM TO DESCRIPTION(color,hardness,soil/rock e, rain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) -
I'
4.Date Well(s)Completed: 1/18/2023 well ID#FS 2058- ft. ft.
Sa.Well Location: ft. ft.
Salem Uniform Facility ft. ft. FER e
Facility/Owner Name Facility ID ft.
#(if applicable) ft.
4015 Cherry St, Winston Salem, NC 27105 ft. ft. ° "ti'�"°�°�'ry;' i r Unt,
ft.
Physical Address,City,and Zip ft.
Forsyth County �:-21.REMARKS
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) 2 er fieation:
N w. 1/25/2023
6.Is(are)the well(s)oPermanent or x�Temporary 'et of Certified Well Contractor I Date
By signing this form,l hereby certify that)the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: t3Yes or E)No with 15A NCAC 02C.0100 or lSA NCAC 02C.0200 Well Construction Standards and that a
!(this is a repair,fill our known well construction information and explain the nature of the copy of this record has been provided to the,well owner.
repair under 721 remarks section or on the back of this form. Ii .
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 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also atjach additional pages if necessary.
drilled:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 45 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2 a100') construction to the following:
10.Static water level below top of casing: n/a (ft.) Division of Water ResoureIes;Information Processing Unit,
/f water level is above casing,use"+' 1617 Mail Service Cenkte ,Raleigh,NC 276994617
It.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 �o i within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.anger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Cen'terl,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c. For Water SuaDly & Iniectionl�Vells: [n addition to sending the font 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 1cottnty health department of the county
where constructed. I
Form GW-1 North Carolina Department of Environmental Ouality-Division of Water Resources Revised 2-2?-2016