GW1-2023-02971_Well Construction - GW1_20230425

' WELL CONSTRUCTION RECORD For lnecrnnl Use ONLY.
? The farm can be used for single or multiple Fvcfis
D.Well Contractor.Information:
Zach Thompson FRONT 'M OFSCRIPTION
WA CotnlractorName ft. ft'.
ft. rG
4478A
NC Well Contractor Certification Number fl5'OUTER CASING(foc`raaGi aased{ceEls OR F:1PiER rtr a"Fleabk
FRONT -to DLA6fETM TrltCi�VEss MATERIAL
SAEDACCO Inc 0 (L 32 fL 2°. in: SCH-40 PVC'
Caugpwg Na lac - id.INNER CASING OR 1'DBING eaiiermal closed-loo
6'ROSt TO DEMIETER TrIfCANES3 MATERIAL
2.Welt Construction Permit[r: R. R;
t ur afl cpplirabfc K elfpcz»cfts(i r.Caunrv,.TW.+r.•Uariarrcr•Itya[Daq'cfr.)
R. ft. is
3.lVd1 Us (c"k Well use): EVSCRUN
Water Supply Wdl: FRONT I TO DMUF.TFIZ SroTSUM TItlClcMS I MATnRrAt.
❑Ag�ecidn(lal, ONfunicipalftblic 32 rt. 42 ft. 2° it'. OSO SCH-40 PVC
®Geothefmal(Healing/Cooling Supply} ®Residential Water Suppb*(single) (L (L [n
Dindustrial/Couuncicial ®ResidentbL Water Supph'(slated) IorRQ� f0 hGaTERtkG fHVT NrEiROD&AhtOtfNT
❑Itri' ti0n 0 ft. 26 fL Portland Injection
Aron-Water Supply Well:
Ihlhlonitoripg i7Rccoscy R.' ft.
Iujeclion Well: • ra
❑AgteifcrRccGar9d C]Goundwatcrilcmcdimioii 19:'SANDIGRAVELVACK(it iilleabte)-
- TO AlATF.Rf41. H�IPLA ..9i:VT MISl1(In
MiltlrfcrStora�, 1WRecovery' El Salinityl3ariier FRONT
R. 42 R. Filter sans #z,
❑AgnifcrTcst ❑Slormmtcr Dia twig
te. rt:
❑Expeiimcaf,'tl Toehnotogy ❑Subsidence Control
`20.D1RILLIING'I.OG(attach additional sliedf it necessary
❑Ga othenmd(Closed loop) ❑Tracer FRo3I TO DFSCRIE1`101i,nbr.havdlucy4 wiumcrc in chute{
❑Geothermal(Reatinr)lCooting Retunl). ❑Otter(Lxplaia under 421 Rernarles) 0 ft; 28 fL, Brown silty clay
28 fL 42 fL Rock
4.DateNe11(s)QmpleI4 3/24/2023 WCUED#MW79
rt.. fL
sa:rvdl Grcatinn: rL rL
The Cleaners R. ft. Z
t/
Facility,Owner Name Facility ID (ffapplicablc)
200 Jonestown Rd., Winston-Salem, NC, 27104 R. ft. U V-10.6DO
U
Physical Address.City-and Zip =;2L REMARKS'
Forsyth Bentonite Seal from 26-30'
County tercel Widifc.1flon No.(PIN)
:5b.,Latitude and Longitude in degrees/minutcslsceonds or decimal dMrccs: 22:Certification:(i!v�ett rigid,tow 130ons is SuM1 i0rat) +���g
36.0787 j+ -80.3364 �V � ' — � 4/3/2023
igmturcofCeitifn:d Well Contractor Date
6.[&(are)1he.Well(ec): EPermaneat or ❑Temporary .N.,un Nair term,t hercb tern rhaf the n•dl al kvs wrrel cwrtrrnrctcrt ice rnaorrlmirr
�3' S 8 f )' Jt' i r
avith l5A NCAC 02C,01M or 15A a{`CAC 02C.O.100{till Coaiseakdon Stmulards and Mara
7.[t tb.is a repair to an eeistiugwell: ❑Yes or ®No. rortro}•dair record hasbecn pirvid,'d(0-0,7 urll mviter•
!f rhls is o repwir,fill otit kal;671 lVell eatueriicNow brformarlon marl iaplaht the nature of the
relmirmndcrd"_l rcmarfk' srrriun or m tan burl•of this form 23:Site diagram or additional w'dl details:
You may use the back of this page to provide additional%veil site details or ti'elt
8.Nuurberof wells constnta tot: 1 construction deiails. You may also attach additional pages if necessary.
For iutdriple.bVavrlpn or non-lr6rer supplr ivells ONLY idth the artite•constri4don,yoir can
sa&,nFtonc jomi. SURN11rTAL INSTUCTIONS
9.Total well depth below land surface: 42 24a. Fdr All Wells:; Submit this form within 30 days of wurplctibn of with
For anairlpie wells list aft deprbs IfdWrew(crmook-Joe 200'diul2@ IM) eon.5IruWan to the following;
10.Static Water level below top of casing: (fd) Division of Water Rexotirces,Dnf tratation Processing Unit,
If nurer level 1,above cnthtg,'use"+" 1617 Mail Scn•ice Center,Raleigh,NC 27699-1617
If.Borehole diameteer..4° (in.) 24b.For Fljtrriott MAls ONLY: in addition to sending the fotnt to ilia address in
24aaboee, also submit a copy of this fotta witbiD'30 days'of completion of well
12.Well construction Method:HSA/Air Rotary eonsimctiard to thte following:
(Lc.augen rot*.cable,direct push sec:)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY- 1636 Mall Ser vice Center.Raleigh,NC 27699-1636
13a,Yield(9pm) )rletbod of test: 24c:For Water Sueltl_r 'ak rnjcctioa Wcib:
Also submit one copy of this faro within 30 days ofcomoletionof
13b.Dkinfectiou tvpt: Amount: well Construction to the county,health department of the county where
coustnictcd.
Fortu GW-1 North Carolina D pcuimem of Em'irotuncntand Natural Resources—Dlvislon of Water Rmut Revised August±v13