GW1--04079_Well Construction - GW1_20230622

,Print Form 71
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: 1
Terry White 14.WATER ZONES . .
Well Contractor Name FROM TO DESCRIPTION
3287-A 27.74 ft. 60 ft.
ft. ft
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable) - ,
ET FROM TO DIAMETER THICKNESS 1 MATERIAL
WIO4OO599
`(� ft ft. in.
Company Name 16.INNERCASINGORTUBING(geothermal closed-loop)-- - -
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
Gist all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0 ft. 45 ft 2 'n• sch40 PVC
3.Well Use(check well use): ft. R. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public 45 ft. 60 ft. 2 in* 0.010 sch40 PVC
Geothermal(Heating/Cooling Supply) ,Residential Water Supply(single) ft ft. in.
Industrial/Commercial D Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 3 ft 42 ft Bentonite Poured/700LB
Monitoring DRecovery 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 E3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage 42 ft 60 ft. #2 Sand Poured
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) x[Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soil/rock type,Brain size,etc.)
ft. ft' See Consultant Log
4.Date Well(s)Completed:6/8/2023 Well ID#I W2-4 ft. ft ��--^�•
5a.Well Location: ft' ft
f�- -w T � '�
p,.-, -. 'A .`
ft.Former Manufacturing Facility ft. (}
Facility/Owner Name Facility DM(if applicable) ft ft. J l j N 2 2023
2744 West Mountain St. Winston-Salem 27284 ft. ft. �it;,f�rf(�' a
.-"*.c> �tlnii
ntc:;~`y
Physical Address,City,and Zip ft. ft
Forsyth 21.REMARKS l
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 Wr / 6/9/2023
6.Is(are)the well(s) Permanent or Temporary Signature of rtified Well Contractor Date
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: DYes or 0No with ISA 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
9.Total well depth below land surface: 60 (f.) 24a. For All Wells: Submit this fdrm within 30 days of completion of well
For multiple wells list all depths ifdii/ferent(example-3@200'and 2@I00') construction to the following: �
10.Static water level below top of casing:27.74 (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 Injection Wells: In addition to sending the form to the address in 24a
AU Lai above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: g
construction to the following: i
(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.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016