GW1--04086_Well Construction - GW1_20230622

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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7
1.Well Contractor,� Information:
Terry White 14.WATER ZONES •
Well Contractor Name FROM TO DESCRIPTION
3287-A 17.38 fL 27 ft.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if sip &cable)
I ET FROM TO DIAMETER THICKNESS 1 MATERIAL
('�(�
ft. ft. in.
Company Name .16.INNER CASING OR TUBING(geothermal closed-loop) -
WI0400599
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) 0 ff. 12 IL 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
BAgricultural OMunicipal/Public 12 ft- 27 ft. 2 in. 0.010 sch40 PVC
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft. in.
RIndustrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
Monitoring
Well:
3 ft• 9 ft• Bentonite Poured/I50LB
Recovery 0 ft- 3 ft• Neat Cement Poured/60LB
Injectionft. ft
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer TestStormwater Drainage 9 ft• 27 ft• #2 Sand Poured
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) O
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,grain she,etc.)
ft. ft- See Consultant Log
6/8/2023 IW3-14 � h-; g
4.Date Well(s)Completed: ft. ft �"�Well ID# _���Y V I"_t
5a.Well Location: ft. ft.
Former Manufacturing Facility ft. ft. JUN 2 /UL3
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
1rlEcma:icn Prc.,.-nos4r.g Ua
2744 West Mountain St. Winston-Salem 27284 ft. ft. DtittQI OG
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 7-m ��,,�� 6/9/2023
6.Is(are)the well(s)OPermanent or Temporary Signature of Cerf d 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: QYes or XONo 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 font:. 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 toj 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: 27 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple we!is list all depths if different(example-3@200'and 2@100) construction to the following:
10.Static water level below topof casing: 17.38
g (ft) Division of Water Resources,InformatioD 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: 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&Infection 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-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016