GW1-2023-01398_Well Construction - GW1_20230208

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WELL-CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: f
RAWLINS CLARKE IV �A4.,WATERZONEs
Well Contractor Name FROM TO DESCRIPTION
4234-A ft. ft.
ft. ft. I f
NC Well Contractor Certification Number
#`75.=0UTER`CASING'forinolfi=cased wells-ORL•INER d Gcable
Clarke Generations Drilling LLC FROMTft- TO
DIAMETER! THICKNESS MATERIAL
ft. I, ;in.
Company Name1'6.IIVNER CASING OR TUBING; iiothermel
2.Well Construction Permit#: UIC Permit W1400523 FROM TO DIAMETER. THICKNESS -i 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.
Water Supply Well: IHT.2SCREEN.•;,r,..r.
FROM TO DL►METERI; SLOTSIZE THICKNESS MATERIAL
Agricultural E)MunicipaVPublic
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.!
Industrial/Commercial ®(Residential Water Supply(shared) ,
18:GROUT-•.
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD I AMOUNT
Non-Water Supply Well: ft. ft..
Monitoring Recovery ft. ft. !
- — Injection Well: ft. ft.
Aquifer Recharge x)Groundwater Remediation
`-A9:SAND/GRAVEL•PACK if a' livable •,' _:.:-:.. '..:, ..-:: : , -
Aquifer Storage and Recovery [Salinity Barrier FROM TO NATERIAL EMPLACEMENT METHOD
Aquifer Test ®IStormwater Drainage
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) [)Tracer ,- DRILtiINGLOG attachadditional sheets ifnecessa
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM ft. ft.To DESCRIPTION color,hardness,soRfrock type,grain size,etc.)
1/13/2023- FS 201a ft. ft. r
4.Date Well(s)Completed: Well ID# �,,, ,� •,
5a.Well Location: ft. ft.
Salem Uniform Facility ft. fr. _
Facility/Owner Name Facility ID#(if applicable) ft. ft.
4015 Cherry St, Winston Salem, NC 27105 ft. ft. In��=� s�� :'r •s•�i�U I,ril
Physical Address,City,and Zip ft. ft. `
Forsyth County 21.REMARKS I °_
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.Cc ' nation
N r W �7 ', 1/25/2023
6.Is(are)the well(s)oPermanent or xOTemporary amre ofCettified WeTContractor Date
By signing this form,I hereby certify that the well(v)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or. Ix No with ISA NCAC 02C.0100 or fSA NCAC 02C.0200 Well Construction 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 T2I remarks section or on the back of this form.
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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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS I
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9.Total well depth below land surface: 47 A) 24a. For All Wells: Submit this(form within 30 days of completion of well
For multiple wells list all depths ijdierent(example-.3@200'and 2@I00') 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 Center,Raleigh,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 thiss form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
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Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Centier,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c. For Water Supply & Iniecti In(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 thie county health department of the county
where constructed.
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