GW1--04088_Well Construction - GW1_20230622

Print Form 7-
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Terry White 14:WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 20.10 ft- 33 fL
3287-A
ft. ft.
NC Well Contractor Certification Number 15.`OUTER CASING(for multi-cased wells)OR LINER(if ap licabte)
IET FROM TO DIAMETER THICKNESS 1 MATERIAL
ft. ft. in.
Company Name
WI®A o o�AQ 16.INNER CASING OR TUBING(geothermal closed-loop) . _
2.Well Construction Permit#: `'F 99 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i,e,U1C,County,State,Variance,etc.) 0 ft- 18 ft- 2 in' sch40 PVC
3.Well Use(check well use): ft. ft. in.
17.SCREEN "
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public 18 ft- 33 ft- 2 in. 0.010 sch40 PVC
Geothermal(Heating/Cooling Supply) DiResidential 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 fa 15 ft- Bentonite Poured/300LB
Monitoring ®Recovery 0 fa 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 0Salinity Bather FROM TO MATERIAL EMPLACEMENTMETHOD
Aquifer Test 0Stormwater Drainage 15 ft- 33 ft. #2 Sand Poured
Experimental Technology 0 Subsidence Control It. ft.
Geothermal(Closed Loop) QTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) pi Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/roek type,grain size,etc.)
ft. ft. See Consultant Log
4.Date Well(s) 6/8/2023 IW3-12 ft. ft.
Completed: Well ID# �} t: • 2. r;.=.
5a.Well Location: ft ft ' ' .-. t a
Former Manufacturing Facility ft. ft. JUN r 2023
Facility/Owner Name Facility ID#(if applicable) ft. ft.
2744 West Mountain St. Winston-Salem 27284 ft. B. lni ra atic m Pro;' i< Ur•,;
Physical Address,City,and Zip ft. ft. ""Q'"OC
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 tat/long is sufficient) 22.Certification:
36 06 49 N 80 09 45 W 6/9/2023
6.Is(are)the well(s))Permanent or EilTemporary signs Certified 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: IjYes or XNo 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 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
9.Total well depth below land surface: 33 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths(fdifferent(example-3@200'and 2 rt 100') construction to the following:
10.Static water level below topof casing:20.10 ft
g• ( ) 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
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