GW1--04093_Well Construction - GW1_20230622

I jr-Print Form I1
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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.Well Contractor� � Information:
Terry White -14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3287-A 15.44 fa 32 fa I
• ft. ft. i I
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if op Beable). .,
I ET FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name WI0400599
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. 17 fc 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 17 ft• 32 fr. 2 in. r 0.010 sch40 PVC
Geothermal(Heating/Cooling Supply) EDResidential Water Supply(single) ft. ft. in.
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
Irrigation FROM -TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 3 ft• 14 ft- Bentonite Poured/225LB
Monitoring DRecovery 0 f- 3 ft. Neat Cement Poured/60LB
Injection Well:
ft. ft.
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery OlSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage 14 ft. 32 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) licl Other(explain under#21 Remarks)
ft.
See Consultant Log
4.Date Well(s)Completed:6/8/2023 Well ID#I W3-6 ft, ft.
5a.Well Location: ft q ... Z
ft. ft. "' "r_z hit-.
d
Former Manufacturing Facility N,,,�(,,,���,, t-;;µ,,;
Facility/Owner Name Facility IDS(if applicable) ft. ft.
2744 West Mountain St. Winston-Salem 27284 ft. ft. JUN 2, 2 202'3
Physical Address,City,and Zip ft. ft. WV'ir�1Jc;l?r.c.;:;w.-ing link
Forsyth ,21.REMARKS ,. •DV,`Qiu...i : ., "
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 6/9/2023
N W IQ%L2 . IN
6.Is(are)the well(s)Jx Permanent or I©ITemporary Signature of Ce ed Well Contractor Date
By signing this form,I hereby certlfr that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: EYes or ENo with I5A 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: 32 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@I00') construction to the following:
10.Static water level below top of casing:15.44 (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 Infection 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