GW1--04084_Well Construction - GW1_20230622

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Terry White 14.WATER ZONES ' .
FROM TO DESCRIPTION
Well Contractor Name 17.01 ft- 30 ft
3287-A
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
C
ft. ft. in.
Company Name WO 10400 rJ 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. 15 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 DMunicipaVPublic ' 15 ft. 30 ft• 2 in' 0.010 sch40 PVC
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 3 ft, 12 ft. Bentonite Poured/180LB
Monitoring DRecovery 0 ft• 3 ft. Neat Cement Poured/60LB
Injection Well:
ft. ft.
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage , 12 ft 30 ft. #2 Sand Poured
Experimental Technology D Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain sae,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) ft. ft. See Consultant Log
4.Date Well(s)Completed:6/8/2023 well ID#I W3-15 ft. ft.
5a.Well Location: ft. ft. r.. :i Sr
Former Manufacturing Facility ft. ft �* _$V "
Facility/Owner Name Facility ID#(if applicable) ft. ft.
2744 West Mountain St. Winston-Salem 27284 ft. ft. JUN 2 2 2023
Physical Address,City,and Zip ft. ft. ltlfli it-.a3:icn Proc:3 tl Lin.
Forsyth 21.REMARKS "` UM/ZOO '
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 80 09 45
N W % GIPub 6/9/2023
6.Is(are)the well(s))Permanent or DTemporary Signature of rtified Well Contractor Date
By signing this form,I hereby cert'that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: EJYes or xlNo 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/121 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: 30 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdterent(example-3@200'and 2@100') construction to the following:
10.Static water level below topof casing:17.01
g• (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
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,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.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources ' Revised 2-22-2016