GW1--04081_Well Construction - GW1_20230622

IF Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
;,
I.Well Contractor� � Information: i
White V V h ite 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3287-A 21.52 ft 36 ft.
ft. ft.
NC Well Contractor Certification Number 15:OUTER CASING:(for multi-cased wells)OR LINER(if ap licable)
I ET FROM TO DIAMETER THICKNESS MATERIAL
/� ft. ft. in.
Company Name V V I�®�q 10 `A�52 .
.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.U1C,County,State,Variance,etc.) 0 ft, 21 ft• 2 m• sch40 PVC
3.Well Use(check well use): it. ft. in.
Water Supply Well: 17:SCREEN ;
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ElMunicipal/Public 21 ft• 36 ft• 2 in. 0.010 sch40 PVC
Geothermal(Heating/Cooling Supply) OResidential 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• 18 ft. Bentonite Poured/375LB
z Monitoring DRecovery -0 fa 3 ft• Neat Cement Poured/60LB
Injection Well: ft. ft.
Aquifer Recharge DGroundwater Remediation
19:SAND/GRAVEL PACK(if applicable)'::. '`
Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD'
Aquifer Test 0Stormwater Drainage 18 ft. 36 ft• #2 Sand Poured
Experimental Technology Ell Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING.LOG(attach additional sheets if necessary) : `. • '. °`
Geothermal FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
(Heating/Cooling Return) Other(explain under#21 Remarks) ft• See Consultant Log
4.Date Well(s)Completed:6/8/2023 Well ID#M W Cs 17 ft ft.
5a.Well Location: ft ft rn,-,,, a, f. c'^
Former Manufacturing Facility ft. ft. r*tt L`.e,� A -rr•
Facility/Owner Name Facility ID#(if applicable) ft, ft' I 1 I N 6) 2 2023
2744 West Mountain St. Winston-Salem 27284 ft. ft. IV
Physical Address,City,and Zip ft, ft tfli�iiiYr3 d^'1�ro`G 3..'"g 11rr�
Forsyth ;
.21:""REMARKS. .;':: ,:,.: •�,:. ., •
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: •
(if well field,one latllong is sufficient) 22.Certification:
36 06 49 N 80 09 45 W — 61),6.. 6/9/2023
6.Is(are)the well(s)0x Permanent or Temporary Signature ertified Well Contractor Date
By signing this form,I hereby certf that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: IJYes or x,}N° with 15A NCAC 02C.0100 or 1SA 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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:one SUBMITTAL INSTRUCTIONS
I .
9.Total well depth below land surface: 36 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below topof casing:21.52
(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 Iniection Wells: In addition to sending the form to the address in 24a
14U er above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: g •
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
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&Iniection 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