GW1-2023-02972_Well Construction - GW1_20230425

WELL CONSTRUCTION RECORD For facmd Uw ONLY;
-'this form can bcused for single or rnultipk Twills
1.Well Contracto r Infoi'niatian:
14t.►dATERZONES,
Zach Thompson FROM To DESCRIMON
Well Contmclor Name R. ft.
4478A
NC Well CardmclorCcniftcation Number 15 OUTER CASING((bs mu[ti-aascifvsells ORLU*31 Mi `Ik bleV,
FROST TO DEALfTETER TEIICitDrESS hIATERTAL
SAEDACCO inc 0 ft. 1 25 (L 2" tp SCE-40 I PVC
Coven:ur}•Nantc 16.INNER CASING.0R Tf1HIW 'suothermal close 400
FROM TO DC4\tETER THfCKNM MATERiAL
2.Welt Construction Permit it R. ft,
f iu(rfd aj�licrrble xi 1l peareits(Lie County,Suae,Ypriarece.Iryerdarb efr,.J
ft.
r tt ire
3.NVc 11 Use(checkwcll use), 17 SCREEN
Water SupplyVVelft FROM TO urAM TER Sr.Orsim THICKNESS MATERiAL
f]AgtiCulttttal f]&IunlCjpallPub)IC 25 ft. 45 ft, 2" in, 010 SCH-40 PVC Pre-P Ck
13Geothetntal(Heating,Cooling Supply} ®Residential Water Supply(single)
®indusuiaUConuncieial OResidential Water Supply(slated) FROM TO
To nrATLrettAL Eb[PI hCE\SENT h(Ef110D AhTODNr
❑hii Gan 0 ff. 14 ft Portland Injection
Nou:Water Supply Well:
re. rt. '
monitoring I]RCcorcry
Mt cliotl Weil: ft. t4
E3AquiferRcghjrgc I]Gtoundvn.let Rcntcdialion tv SAND1GR.A.VELPACK(if d;uDtYl
FROM 'molt , MATFRIAI. PMPI.ACr ir:.Nrmtrunn
I]Agnifcr Storage wid Rccoi•CIy' ASalinity Hariicr 23 R. 45 ft. Filter Sand #2.
I]AquifcrTcst ❑Stommatcr brainagc
OEgicrimcotal Tcchnotogy ❑Subsidence Control
10.DRILLiil1 G'LOG(attach addillorial'sbcets if hemsan-
I]Geotitentml(Closed Loop) OTricer FROST TO DESCRIPTTOv wis.bartfnea wa'nuktr o ue 0
OGeotltennal(ReatingrCooliti Relunr} pother(explain under 421 Rettrntl s) o tt: 16 fL Brown silty clay
16 fL 45 (L Rock
4.Date*&(i)Cbntplcled: 3/29/2023 WdIIDpMW-6 .
54.Wail Location:
The Cleaners tt. (L Q't3
Facility,0"mrName F&fl ty IDk eiCupplimblc) A
It ft.
200 Jonestown Rd.,'Winston-Salem, NC, .27104. rL (t. N , yata "
PbyijCal Address.City.and Zip a24 REMARKS
Forsyth Bentonite Seal from 14-23'
0muly Pared MulificilloaNn;(P1Ny
5b.Latitude and Longttade in.dctircec/minutes/sceonds or decimal degrees: 22 Certification.
(1f«ell lord;etas'I.�L7oug 1$Stfi7eienl)
36.0784 N -80.3350 4/3/2023
%gluture Connector Dale
6.Is(are)the-well(s): M,Perlitartenc or. .DTemfWrary. L4�argning this farm,f hereby rerfif.•mint Me,r•ol(N)w'(wr,r,canii wfed in aeco,inincr
avth 15A NCAC 02C,ol@']or 1 iA NCAC 02C,t72M Well Corrstrrerfon Standards and 0wr a
7.IS this a repair to an VQi-stina►►t'ell: 0YCc or Mn, copy of(hir record has burn pr»ridr'd ra dw..uNI''Mmer,
if rhis'Is-o retch-.fill.ur kirrdra rsrU crnummion brfonrurrl on wid explain r1je nareue of(fie
repairrurckr 021 rrurarkv 3ircfiaa or an the back oft&is farnL 23.Site diagram or additional well details:
You ruay use the back of this page to pfo►'ide additional well Site details'or well
8.Numberof wells constructed: 1 constiuctlori details. You ittay alsb attach.additional pages if necessary.
For mrdflplc lr0'err)vn or nevi-risararsupplp wells ONLY n'lrh the blrrnRCJrtStlrrerl0lr,}ar Can
sa0mir one form SUBAIUMAL iMI_TCTTONS
9.Total well depth below land surface: 45 qp 24a. Ear Att Wells Subinit.this form within 30 days of completion of well
For malflpfeivelts list alldeprhsIfdifferenr(erampfe-d@2oo'oml2@f( )* conslnictionto[hefoltowina;
10.Static Water level below top of casing: Division of Water Resources,Lformation Processing Unit,
If nnrer lei ef.ls above Fuca,ase"+" 1617 RUH Sen•ice Center,Raleigh,NC 27699-1617
Ill.BorchoEe diameter.4" (in.) 24b.Lnr fnlCCtJ,1a Weflv.(DNLY: in addition to.sending flee fonu to the address in
244abo►'e.also submit a copy of this fotin within 30 days of completion of well
12.Welfcoustmetionmethod:HSA/Air Rotary construction totitefollowing:
(Le.auger.-rotary',cWe.dirca.pnk erc.l - - .
]$[vision of Water Resourcei,Underground Inje'eliott Control Program,
FOR WATER SUPPLY WELLS ONLY, 1636 Mail Service Center,Raleigh,NC 276"-1636
13;t Yictd(Apr) 111Cthod of test-
Also For Water Supply.4t'Injection WCI19:
Also subtuit one copy of this fofut within 30 daysof completion of
13h.Disinfection t,�Trr: Amount- well construction to the cotmry health depariment of the counh<where
coastnictcd.
Funu MV-f AbnhCamlina DeWilment of Emirounkm and Natural Resources—Division of'Mater Resoulca Revised ALWnt 1013

i
WELL CONSTRUCTION RECORD � Far 110MA vSC ONLY:
-7 This farm can ire used for shigic ai multiple%wits e
1.Well Coutrictor Information:
IA:WA•1'LRZONES
Zach Thompson FROM TO DFSCRIM09
W01 corAMC1004.InN: R. ft. -
fL rL
4478A
NC Well QiwctarCcdifuation Nurnber fl5.OUCER CASING roe iun[tl risrd'eellsl'OR LINER fit a"ticable
FROM TO TFUMETER I THICKNESS I MATERIAL
SAEDACCO Inc 0 fit 1 30 (L 2" to I SCH-40 I PVC
Cottp aiq-Naaip M iNNER'CASiNG OR-TIIIBING' eoihermal cloud-loo
FQOM To DGIIIETER THiCKNESS I MATERIAL
2.Wcii Construction Permit#: R. ft, 116.
Liu all npplirabre%,711 pea is(i e.Canmty.Tiate.•Variarrce.Ilhrada&e1r.)
a. rt. iir;
3.*dImse(ch ck-well ase): t7:SCRIfEN
Water Supply Well: FROM TO nrANTF,TM SLOTSrzt; TntttcrESS I MATMAL
Mgttculnual ONfunicipat. tcblic ae ft. 50 R. 2° itr. .010 SCH-40 PVC Pre-Pic.k
DGeotherim1(.Heating/Cooling Supply) ®Residential Water Supply(single) (L fL �a
®hrdustrialfiComnicicial ®Residential Water Su (shared) te.GROUT ..
Supply FROM M TO ATATERUL I EMPLACEMMIT NiETTIOD S,"10U T
171rri 9tion 0 L 23 ft. Portland Injection
Non-Water Supply Well:'
ft. ra
Mlo-lonitoring pRccotrrg
Injection WC.U: (L
OAquifcrltcc.Mrge ®GioundwalcrRcmcdiation t9-SANDIGRAVEL PACK(if tdk;&bte
QAiinifcr Storage and Rccaycry' 17Salinity 13amcr FROM Ta A(ATHftv%r: FAiPt.A(:t:VENT Aft.runn
28 It. 50 ft. Filter Sand #2
❑ quifcrTcst ❑Stomm-itcr Drainage
'fL rt.
ORNperimcniai Tcehaotogy OSubsi&.ncc Conliut
20?DRILLTNG LOGfatlach addhionalittedii(aecemuryl
inGeodwrt tal(Closed Loop) OTracer FRONT TO VESCRIMON(mbr.harditese wIlIn cte( hi we cW
OGe(rlltennil(IIeatinglCao[iD Retunl}, _'OOtI>er{e-plain under 921Reuiatcs) 0 fL 24 M. Brown silty clay
24 fL 50 fL Rock .
4.Date We11(9)Ca'Dipleted: 3./2212023 Wetl i D#MW-7
ft.. (t. '��+ �6Vtt�
5111.Well Loeatuin: tL rL
The Cleaners rt. (l. APR
Factliiq,OtivncrNarac Fact7itlll)g(tfapplicabie) R. ft. 1^tUr9A
200 Jonestown Rd., Winston-Salem, NC, 27104. rt ft.'
Pliyskd Addicss City_and Zip REh1ARIH4'
Forsyth BenEonite' seal from 23-28'
Caaetly farce]IekatirtC,9I1on No,(PIN)
56.Latitude and II nngitadc to dcgncclminutes/seconds or decimal ate rocs: 22.Certifecatitra.
(IrITTM rigid;Brie i IlAong is s,J(ickw) /�/
36.0780 N -80.3357 W. - --m om 4/3/2023
i ftjmorCcitificdhid1Cantrtctnr Dale.
6.is(are•)the-w•ell(s): MPerrnanent or. OTemporarg 1h'_slgairig lbix form.1 Prerchy rerrifv That ll,r u'e41(sl xw•(Krm)cominrcfed iir aec'orrA.anCe .
with 15A NCAC 02C,010)or(Set NCAC 02C,02(47 Well Cossove dour Sramiards and Afra
7.iN this a repair to an evstin„well: 5 lVe s or ®ND. COpT aI(hlS MCO!Yl hQ51h%rn pr,lrid,d rr.r5r rn*il me„er,
if tir(s Is a repair,fill,xer laivim isdl cotwntcdoa bifotmarhm and eaplaht the&&rare of(fie
repair umlerA31 remarks•srcliarn or on the brisk of this fora. 23.Site diagram or additional%veil deWN-
You may use the back of this page to,provide additional well site details or tiell
S.Numberof wells coastruLted: 1 constmetion details. You stay also attach addlidonat pages if necessary.
Fur mule(ple ItVj erlodor awisinrer sitglilr wells II,YLV w1rh the dfrf17BC0r(S(l((C1FAJ(.141t Carl
sahnu!one fnrra. $UBMUTAL INS'1'UCTiQNS
0.Totat well depth below lwd surfaw. 50 (ft.) 24. Ptir All Wells: Submit this farm within 30 days of completion of well,
For ltraftlple wells list alldeprhs 1fdff'errnr(cx(apfe-3@201r'arul2@14w)) conrilmctign to the following; '.
10.Static water level below top of easing: ({I,) DiA$siuu of Water Rcsources,Inf r.matian Processing Unit,
1f nnrev leL,d is above cadog;ate"t" 1617 Alan Sen•ice,Center}Raleigh!vC 27699-I617
114 Borehole diamctcr.4" (in.) 24b.For fnlcction'Wellc ONLY: In addition to.sending the form to the address in.
24aabove.also submit a copy(if this faun within 30 daivs'of completion of well
12.Well construction method:HSA/Air Rotary Construction to the foUowhtg:
{LC.3LLgCf.filar}'.CabiG direct push C(C.) �
Division of Water Resources,Underground Injection Cantrol Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service'Center,Raleigh,NC 27699-1636
134L Vidd(glrm) Method of test: 24e.For Water Supply&.1nieetton Writs:
Also submit one cope of this fora-within :0 days of completion of
13h.Dkinfextion type: Amounh «c11 constniction to the counly health department of the coirnh•whew
consmmcd.
FerniGWA NonhCarallmDepanatentofEmimnnrtu and%owalResowces-Divid000fSVoierRe�otrcm ttCV.ised LWist2ul3

WELL CONSTRUMON RECORD For tacrual Use ONLY:
:Nfs form can be wwd for single or multipk kAvEs
L.WoMatratctor Information:
iJ.AVATLR ZONES
Zach Thompson FROM 110 OMCR1Frla)!(
%V01 Co.iractorName R. R.
4478A
NC WJ1 Cau=1orCert F=tion Number 15 OUTER CASING(foe mufflAuseil�ie11s OR LfNER it u f "[ica6le'
FRO.r !) DIAM
ETER
TIn , 55 MATERUL
SAEDACCO Inc 0 ft, 30 ft. 2". fi.L SCH-40., PVC
Coin uLy N*nw .INNFR CASING OR`TUBING eeikrmnf elosed4oa
FROM- TO - DMIETER THICKNESS MATERLIL
2.Well Construction IMTait R:
Gist cull rlrplirntalr.x ell peirtrlts(la..Cuunry.Stai:e,lrariarwe.Irayerdaq esr...)
3.FVdI.13sc(chCci:wcll asc): L7:SCREEN
Water Supply Well.* FROM TO DFAMRTF,Et SLOTSIM. TNICi MS I NTATMAL
❑Ag[nul[ural C11GIuniCipaUPtc61iC 30 ft. 50 R. 2" 11L 010 S6H-40 PVC Pre-Pick
ClGeodwimal(Headrig,7Cooling Supply}. Residential Water Supply(single) ft ft, in
®Tndustrial/CoRmtetcial ©Residential Water Stippn'(shared) 'IS.-GROUT
FROM TO MATERIAL MMACE\fM MERIOD&AMOUNT
I]hri lion 0 fG 12 R. Portland Injection
Noa:Water Supply WefC:
ft. ft.
�hlonibring Mccoti-cry
Injection wea: rt. ft.
17AquMrRcctrargre 06wundRatcr1tcmediation Iq:SAND1GRA.vt?LPACKfit ailrue�nt�
'FRONT TQ MATMAL RNIPLA(MUFNT VAIM1013
❑AiplifcrStoragcanditccoccry l7 ilinityHardcr 28 ft. 50 ft. Filter Sand #2
l7AgnifcrTcst ❑Stormnatcr.Drawagc
rt. rr.
❑1=.rpcdiucn1al Technology 175nbeidcncc Coloral
'20:,DVJL'LLNG1OG"laltacd Addltionalshcefa if ncccsmn
❑Geodiennal(Closed Loop) ❑Tracer FRONT" TO DPscRtfrtDv rmFar.hardnca,w4'rnckh n Rae.cre t
❑Geothermal(RealinalCooliug Return) ❑Other(explain under#21 Remark 0 fL 13 ft. Brown silty clay
13 fr. 60 fL Rock,
4.DateWeU(9)Can1plere& 3/28/2023 WalID#NW-8 .
f4 ft. 3 I°1sr r i' p
54.Well I ocathin: fL ft.
The Cleaners ft. fl 023.
FactMWoDwocrNam.: Facility U)M(irapplicable)
hibim-A..
200 Jonestown Rd.,.Winston-Saiem, NC, 27104 ft. ft. DWOJWJG
Pigsical Address.City.and Zip :21:REMARKS
Forsyth Bentonite seal from 12'-281 and 50-601
Couut3' Parcel Id'.111ifcalionNo,(PIN)
ib.I;atitude and Longftudc in degrus/minutcstsceonds or decimal degrees: 22,Cerfifecatioa:,
(If.,clt Ucld,one l:unong is%unicknd)
36.0785 N =80.3371 W 4/3/2023
Sigmim a afceitifred Well Contactor Date
6.Is(are)themell(s): EPerwanent or ❑Temporatty hj.signlrig thls farm.I hercbr'eerfily dear the iro(s)war(i4rr!)conyinicred hr aevvidance
with RM NCAC 02C.0100 or ISA NCAC 02C..0200 Well Construction Suuufaids and dear a
7.Is this arepairtoaneaiNtfnRwell: MYm or MNo. capen3rlilrrernrrllaesInrnpmru(edroatr:arilinrner.
!nuts is o repair.fill[xat kr,t;un well consttualoa Itaforrrrmlon amdexplaln the narare of the
repair r.1,921 remarks srraima or an due b wL-of this'form 23.Site disWe am or additio nal%veil detm it
You may use the back of INS page to provide addilionat well site details or well
S.Numberaf wells constructed: 1 coistrnction details: You mat'also attach additional pages if Necessary.
Forruiilriplc lyderrlon or 0ai-!51&er supply wells ONLY ndrh die untrue caarWIM1l0rr,you can
sulrnait one form. �SUBdfCI"1"AL WSTUCTiONS .
9.Total wc�ll depth below land surfvce.- 60 ((14) 24a. For AU Welly:: Suhmit.ttiis fumy within 30 daps of completion of well
For anarlrlpfe welh list alidepths lldlf erens eex4m1pl..;?@e 20f1'dnd 2@1001 eore5inleti4n to-Ilic,foitiing:
10.Static Avatter level below top of casing: (ft.) Division of%tcr Resources,Ia£ormation Pracessing Unit,
!f nnt�'r level Is obuvt cvaslrag.cast"+" 1617 Mail Seffice Center,Raleigh,NC 27699-1617
11:Borehole diameter.4" (in.) tab.i'nr Ti feeeion Welly ONLY: In addition to,sending the form to the address in
24daboee. also subunit a copy of this forth witlrite 30 days of completion of%vil
12.WCH aoustr ctiou method:HSA/Air Rotary consiiuction to the following,
(Le.3a^gm rotary.CaNe.direct pass C(C.)
Division of Water Resources,Underground Letjection Control progrjai.
FOR WATER SUPPLY WELLS ONLY: i(636 hull Sri'ice Center,Raleigh,NC 27699-1636
f3a Weld(gym) Method of test: 24c.For Watcc Stipplr&Injection ovals:
Mw submit one copy of this form within 30 days ofeampletionof
13h.DisinfeLtiun type: Amount:_ _ well consiniction to the county fteallh department of the coanh•wWrc
constnicicd. I `
i
Fonu GW-1 NoilkCauaW Ek-,pa nment of EMio(ment and Naraml Rcmurces—Division oMalei Resales Revised August 21113