GW1--04089_Well Construction - GW1_20230622

11
r Print Form .
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Terry White 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION' i
3287-A 21.50 ft. 41 fL
ft. ft.
NC.WeII Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if tip'licable)
I ET FROM TO DIAMETER THICKNESS 1 MATERIAL
ft. ft. in.
Company Name WI
^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• 26 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 DMunicipal/Public 26 ft• 41 ft• 2 in. 0.010 sch40 PVC
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft, ft. in.
Industrial/Commercial E3 Residential Water Supply(shared) Is.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 3 ft. 23 ft• Bentonite Poured/450LB
Monitoring ORecovery 0 ft. 3 ft. Neat Cement Poured/60LB
Injection Well:
Aquifer Recharge 0Groundwater Remediation f ti
19.SAND/GRAVEL PACK(if applicable)' '
Aquifer Storage and Recovery D Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage 23 ft• 41 ft• #2 Sand Poured
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional'sheets if necessary) ,
Geothermal(Heating/Cooling Return) .Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soillrock type,grain size,etc.)
ft. ft. See Consultant Log
4.Date Well(s)Completed:6/8/2023 Well ID#1W3-10 ft. ft.
ft. IL
e�^(r!.,I'-P•p f n..
5a.Well Location: •E",
` " ,,- r-e-'-
Former Manufacturing Facility ft. ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft. JUN 2. 2 2023
2744 West Mountain St. Winston-Salem 27284 ft. ft.
ftPhysical Address,City,and Zip DWQMG
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 80 09 45 N W /r ttJ t 6/9/2023
6.Is(are)the well(s) Permanent or 'Temporary Signature of C tfied Well Contractor Date
X
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: IjYes or X No 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:fine SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 41 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii different(example-3@200'and 2@l00') construction to the following:
10.Static water level below topof casing:21.50
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&Inflection 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 OW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016