GW1--04090_Well Construction - GW1_20230622

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor� � Information: ,
Terry White hite 14.WATER ZONES .
FROM TO DESCRIPTION
Well Contractor Name 24.75 ft. 40 ft J
3287-A
ft. ft. 1
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
1 I O A oo C 599 AQ .16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: V M! `t FROM TO DIAMETER THICKNESS MATERIAL
A/
List all applicable well construction permits(i.e.UIC,County,Slate,Variance,etc.) 0 ft' 25 ft 2 in. sch40 PVC
3.Well Use(check well use): ft. ft. 1n.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public 25 ft 40 ft- 2 in* 0.010 sch40 PVC
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft. is
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 3 ft 22 ft Bentonite Poured/450LB
Monitoring 0Recovery 0 ft: 3 ft Neat Cement Poured/60LB
Injection Well:
ft. ft.
Aquifer Recharge D Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable) •
-
Aquifer Storage and Recovery EtSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage 22 ft 40 ft. #2 Sand Poured
Experimental Technology 0 Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
- FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) t Other(explain under#21 Remarks) ft. ft
See Consultant Log
4.Date Well(s)Completed:6/8/2023 well ID#I W3-9 ft ft.
ft. ft.
5a.Well Location;
Former Manufacturing Facility ft, ft. r,:k*r fE
. ft. ft.
Facility/Owner Name Facility ID#(if applicable)
2744 West Mountain St. Winston-Salem 27284 ft. ft. SUN d ZUZ3
Physical Address,City,and Zip ft. ft l r ^'ir'1 ?r;'-rs'As;!s lira
Forsyth 21.:REMARKS " CS't'a''30L1
County Parcel Identification No.(PIN) '
Injection Well for Remediation
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field,one lat/long is sufficient) 22.Certification:
36 06 49 80 09 45 �'�' // 6/9/2023
N W 7 0
6.Is(are)the well(s)JPermanent or Temporary Signature of rtified 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: EJYes or EjNo 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-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: 40 (ft) 24a. For Alt Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths!I-different(example-3@200'and 2@I00') construction to the following:
10.Static water level below top of casing:24.75 , (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.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016