GW1--04077_Well Construction - GW1_20230622

IF Print Form 1
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: j
1.Well ContractorInformation:
Terry White 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3287-A 25.21 ft- 41 ft•
ft. ft. 1
NC Well Contractor Certification Number 15.OUTER.CASING(for multi-cased wells)OR LINER(if hp licable)
I ET FROM TO DIAMETER THICKNESS MATERIAL
qq (� ft ft. in.
Company Name WI 0`'F00�99 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. 26 ft• 2 in- sch40 PVC
3.Well Use(check well use): ft. ft. to
Water Supply Well: Y7.SCREEN, '
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E3Municipal/Public. 26 ft. 41 ft- 2 in. 0.010 sch40 PVC
Geothermal(Heating/Cooling Supply) EpResidential Water Supply(single) ft• ft. in.
Industrial/Commercial °Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL -EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 3 ft. 23 ft. Bentonite Poured/500LB
Monitoring °Recovery 0 ft. 3 ft. Neat Cement Poured/60LB
Injection Well:
ft. ft.
Aquifer Recharge °Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable) '
Aquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD '
Aquifer Test 0Stormwater Drainage 23 ft. 41 ft. #2 Sand Poured
Experimental Technology °Subsidence Control ft. ft.
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Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary) ..
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,Rain s ze,etc.)
ft. ft. See Consultant Log
6/8/2023 IW3-1 ft. ft. _ _
4.Date Well(s)Completed: Well ID#
5a.Well Location: ft. ft ,` �, ads
Former Manufacturing Facility ft. ft. �
I
Facility/Owner Name Facility ID#(if applicable)
ft. ft JUIV d 2�2J
2744 West Mountain St. Winston-Salem 27284 ft. ft. inf r#t ;icn Pro: a:r,g Urea
Physical Address,City,and Zip ft ft '
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)jX Permanent or Temporary Signature of Certi Well Contractor Date
By signing this form,I hereby cert fy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: IYes or X°No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
gilds 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
9.Total well depth below land surface: 41 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdlfferent(example-3@200'and 2 rt 100') construction to the following: i •
10.Static water level below topof casing:25.21 ft
( ) Division of Water Resources,Information Processing Unit,
If water level is above casing;use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter:8 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Augerabove,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,rotary,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. 1
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016