GW1--03529_Well Construction - GW1_20230519

WELL CONSTRUCTION RECORD Q` Far tntcnsal Use ONLY:
This Farm can b.used for single or multiple wells
1.Well Contractor Information: \�
"14.WATER ZONES
Scott Hunt, Jr FRONT TO Dr-icinptn)Y
�'re1lCoransctvrNamc 51 R. 56 ft, silty sandy water zone on top of roc
R. fL
4561-A
NC Well CommclorCenifecotion Nwrbei -IS:OUTER CASING(Mr taniti eased'ncflsl OR-LINER i[f a"flezbk
FROM TO Dt%l%l TER Trnct(NEss NIATERfAL
SAEDACCO Inc 0 fL 51 It. 2" In. SCH-40 PVC
Coalp;usy Name I(i'INNER CASING MR: RING eoiherinit cloud-loop)
PROM TO DUNIETER THICKNESS MATERIAL
2.Well construction Permit n: R, ft, 1,1.
list all alry,lirablr.wellpeimfis(Li',Cn,uuy.Shan.Vanaircr,fryerbeo rir,.)
3.Well iJse(chcClEwdl use): r7:SCRUN
Water 5upph FVell - - FROST To nt•►nti;THR I StMSlrr. I TtuCxN"NS I SIATERrar,
CIAgTicultural ONfltnicipal tblic 51 ft, 56 ft. 2" in. .010 SCH-40 PVC
)]Geothermal(Hcati*Cooling Supply) ❑Residential Water Supply(single) ft ft
❑lndustrial/Conuncicial ©Residential Water Supply(shared) 18.GROUT ..
FRONT TO NIATERrAL EMPLICENIENT MI T►IOD&AMOUNT
❑hTi ;pion 0 1t. 46 ft. Portland Tremie
Non-Water Supply Neil:.
pamonitoring I]RCcovery' n (I.
Injecl Ion Well: f4 (L
QAquifcrRcclrarse M(Srouri malcr11cntcdiation MSANDIGRAVELPACK-1if Islicabl"I'
FRONT To NfXrritm. FiNIPI�Ci;\Ir_NIT MET11011
❑rtgoifcr Stortgc slid Recovery ❑Salinite 13ariicf 49 R. 56 ft. Filter Sand #2
❑AgadfcrTcst ❑Stomm-atcr Drti1T Tpc
❑Exncrimcntal TcOr ology pSubsidcncc C014TOI
'26.DRILLING-LOG(allach adrtlNonal sh eO if accesmn•)
❑Geotltennal(ClosedLoup} ❑Tracer .FRONT TO DFSCRTPTION' wisr,hnrdneti w0Vmicktr,ot nruadrl
❑Ciwtitemtal(lleatin,,fCooHo2Return) ❑011ter(expinin under#21ReLua&) a ft. 20 fL dry compact silt
20 fL 45 fL silty sand
4.DateNVcll(s)Cotnpleled: 5-8-23 WL41ID#MW-4D 45 it. 56 ft, silty sand arnd-rock-. e_ _
F L
5a,1Vell LAwatioll: ft. (L
A Cleaner World #150 ft. iL MAY
Facilitpi'ownerNaiito Fdcflh)-TDk(ifappli arblc)
ft. ft.
3735 Peters. Creek Pkwy. Winston-Salem, NC, 27127 ft _ ft s + ��<.•• ... ,s;
C�l.i,`•9i��1
Plrysicid Address Cit}.and Zip IL REMARKS
Forsyth Bentonite seal from 46-49'--
Canuta' 1}aice]ItlesiliriCAlion No.(PIN)
5b.Latitude and longitude in dcgiCCs/minutes/secoinds or dechnal dcgrm- 22.Certifiption:
(If«¢Ilfwld.oi�I;tU7pugl,Srdlickul} �f—
N W �C�w _• 5/14/2023
5igmarrc ofCcitirtcd Well Con tar Date
6.LS(are)Ihe.well('!)r MPerntancnt or ❑Temporary H,•signing this form,I kereb}•cerrifl'rhar the well(s'1 r,Tis(F4rxL)consrruered irr ax-emylance
mitt}d&I NOW O;C ARV or I S,1 NGLC 01C.,02101 Pelf Coiuirrrrion Srarinrds and Axrr a
7.LN this a repair to an csistit V.y or ®ND copy of flits record has fn•rn(irovirh'd ro;&troll miner,
ei b( is 5 a relvir,fill wit kovivn v1'ell: ❑
ivn meld claontedon brforai rrl on rtnd e.yfahr rho norrne of die
repair raider d2l remarJ4-sei_•iiun or cvr the brxk of this farnr. 23.Site diagram or additional well delailm
You Ma},use tie back orthls page to provide additional well site details or well
8.Number of wells constructed: 1 construction delalk You trap also atlach additional pages if al cessary.
FortnrrlrlplelrrfeY'rlUn m•nrxT-u'nrer supply mrfls Ofi'LY mlrh rhr samecorrsrnc�dlorr,}soar ena
sa6nuroric faro.,. SCIBNiiTTAL iMUCTiONS
9.Total well depth betow land surface, 56 (n,) 24a. For Alt Welly: Suhttut this fon i within 30 days of Completion of hell
For construction to dic foltati ing:
10.Static water level below tap of casin(;t 20 (ft.) Divisibin of Water Resources,Information Processing Unit,
if srnts'r levy 1!,above Va,164 r,tart"+" 1617 Mail Set-vice Center,Raleigh,NC 27699-1617
11,Borehole diamcten 8.25" (in.) tab.j nr lijiWinn Wc1ic.ONLY. in addition to sending Into form to the.addre-5s in
24aabove.also subunit a copy of this form within 30 days of completion of well
12.Well construction method'HSA construction to the following:
(i.e.augpr.rolar;•,cable direct paste etc:)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY {RILLS ONLY:' 1636 Mail Service Ccinler,Raleigh,NC 27699-1636
13a Vidd(gi►m) Method of test: 24c.For Water Supply&iWcctloai VctLs:
Also submit one copy of this form within 30 daysofcomplelionof
13h.Dlsinfcctiun I.N-per Amount: well construction to the county licalth department of tiro county where
constntctcd.
Fonn G1tr-1 Monh Caralina Depanmient of Enviroansem and Vnnrlal Resources-Divislon of Nnicr Rmautes Revised August_V13