GW1--04075_Well Construction - GW1_20230622

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I` Print Form1
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: I !! ` a
1.Well Contractor Information: 1
Terry White 14.WATER ZONES ,
Well Contractor Name FROM TO DESCRIPTION
3287-A 23.76 f. 40 ft. 1
ft. ft. ; ,
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased welts)OR LINER(if tip licable)'
I ET FROM TO DIAMETER THICKNESS 1 MATERIAL
ft. ft.• in.
Company Name VVI0400599 .
16.INNER CASING-OR TUBING(geothermal closed-loop) �-
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0 ft' 25 ft, 2 in. sch40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 0Municipal/Public 25 ft• 40 ft. 2 hi' 0.010 sch40 PVC
Geothermal(Heating/Cooling Supply) QResidential Water Supply(single) ft. ft. in.
Industrial/Commercial OResidential Water Supply(shared)
18.GROUT
- Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 3 ft- 22 ft- Bentonite Poured/450LB
Monitoring ORecovery 0 ft. 3 ft• Neat Cement Poured/60LB
Injection Well: ft. ft.
Aquifer Recharge 0 Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery OlSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage 22 ft• 40 ft. #2 Sand Poured
Experimental Technology 0 Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary) -
Geothermal(Heating/Cooling Return) Other(explain under#2I Remarks) FROM TO DESCRIPTION(color,hardness soi/rack type Alain size eta)
ft. ft' See Consultant Log
4.Date Well(s)Completed:6/8/2023 Well ID#IW3-3 ft. ft.
5a.Well Location: ft. ft t"�3 's";+l I* f�- p
Former Manufacturing Facility ft. ft. (��Z,,����`
Facility/Owner Name Facility ID#(if applicable) ft. ft. J V N 61 2 2023
2744 West Mountain St. Winston-Salem 27284 ft. ft.
tat:.:r,.'j rt 7rrne„sJ.ri llr•.;i
Physical Address,City,and Zip ft. ft. DWOi' OC
Forsyth 21.REMARKS . -
County Parcel Identification No.(PIN)
Injection Well for Remediation
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
36 06 49 N 80 09 45 W ��, 6/9/2023
6.Is(are)the well(s) Permanent or Temporary Signature citified Well Contractor Date
x
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: lYes or 0No with 15A NCAC 02C.0100 or 15A 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#21 remarks section or on the back of this form.
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:one SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: 40 (ft) 24a. For All Wells: Submit this forni within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3 a(�1 00'and 2@100') construction to the following:
10.Static water level below topof casing:23.76
(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:8 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Auger above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,misty,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply&Injection 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 the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016