GW1--04717_Well Construction - GW1_20230721

'` WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells 1
I.Well Contractor Information: •
IL WATER ZONES
Scott Hunt, Jr FROM TO Dt:_SCRIFTIoN
WeltContrngorName 27 ft. 36 ft., silt sand
4561-A • R• ff. -
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NC Well Contractor Certification Number .LS.00TER CASING(Ibi.tituNkiineitnells)OR-LINER(iS"ati Ncabk)'• ,
FROM TO DIAMETER THICKNESS MATERIAL
SAEDACCO-Inc IL ft. 1 is
Cangrtny Name Id.'INNER'CASING OR TUBING Iseoibernal eloned-loop) ' -
FROM To DIAMETER• THICKNESS MATERIAL
2.Weil Construction!emit#: 0 ' R, 26 ft. 2 hi. SCH-40 PVC -
Liu all apprlirable will pennits(ire.County.Slow,Variance,k fie ba;or.)
' R. fit, In .
3.WcU1.Use(ches:well use): IT.SCREEN
Water Supply Well: FROM TO DtAMI.TER I St.OTSI7E T1UCKN1SS • MATERIAL.
°Agricultural PhinnlcipaVPublic 26 R. 36 • ft. '2 in, 010 SCH-40 PVC
' ❑Geothermal(Heatingicooling Supply) ❑Residential Water Supply(single) ft. ft. in,
❑IndusuiallConutienial ❑Residential.Water Supply(slatted) car GROUT - " .
FROST To. - - MATERIAL ES[P[ACEhfEVT METHOD&AMOUNT
❑irrigation 0- ft. 22 ft. Portland Tremie
Noa:WaferSupply wdf: -
ft. R. ...._LI
RlMonitoring .l]Rccav'ciy
Injection Welt: ft. ft.
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C)Aquifcr Rccbargc .t3Groundwater Rcntcdialion �-t9:SANDIGRAVEL PACK(if,yapiteab[i), . ..
FROM - TO SIATttRIal. 5tlPLACEMENTSrrTH0n
.t7Ailuifcr Storage and Recovery 13Salinity BarWer 24 ft. 37 ft.' Sand #2
t7AquiferTest ❑Stornmatcr Drainage
•ft. ft..❑E tpciiincntal Tcelmotog y ❑Subsidence Control: • -
20 DRILLIi1G'LOG(a tads additional.shcets if ncceasarrt
❑Geodtennal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color.Hnrdnca,so4'mckOnt.py n siee.dr.}
❑GeotitennalMHeating(CoolingReturn) Wilier(explain under#21Retuati;s) 0 : R, 3 ft, gravel 'and fill .
3 ft. 27 ft. silty..clay red .
• 4.Date Wells)Campletedi-5-16-23 -Well IDUMW-7 27' ft,. 3.6 - it silty,sand
$a.Well Location: (y ft.
r... #••
e
vED
Winston Weaver Company R, q;
FacdityKlunerNamc Facility IDS(if applicable) ft, r
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4440 N. Cherry St._ , Winston-Salem, NC, .27105 - R. rt.. - kflSOf1M,-
$'%t 9r
.asetrit Uri
•Phr#ical Address City.and Zip :1t.REMARKS CWQ19OG
Forsyth ' Bentonite seal from 22-24'
Coney Parcel Identification No:(PIN) '
Sb.Latitudc.and Longitude in dcgreeslminutcslsceonds er decimal degrees ZZ.Certification:
(il%rcll field,one/allot is strflick:4)
N WY 5'0:Ott-717Cat . • 5/21/2023
' - S.igruturc of Cehifred Well Con �tor • Dale
6.Is(are)tbe.well(s): XlPermaneat or ❑Temporary.
'Byaigning rlrir farm,I hereby certify this the we?Ms)was(were)cant:meted in,actrarderzwe
-with 15A NCAC O2C,0100 or 1 SA NCAC 02C'0200 Will Constrierlar'Sraradards and rlua a
7.Is this a repair to an.existingwell; ❑Yeti or lNo ,copy oftlhirrecord has teen pmvide.irarlaarilminer,
If rhls is a repair.fill out)anew well cwamrciloa hrforeutriwr airul explain the aware of the '
repair under I2l remarks maim ar on the brxL of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details.or Well
S.Number of wells constructed: 1 construction details, You may also attach additional pages if necessary.
For mulslple lafeerlou arnrrn-rarer supply wells ONLY with the.rmirbce,rstrireaan,yok con
A:giOntifonefomr. .SilliMrTTA1.INSTUCTIONS ,
9.Total well depth helm land surface: 3 6 - (Ip;) 24a. Ear All Wells:, Submit,this'farm within 30 days of completion•of well.
For m illphr wells list otldepths Ifdl,J'erevu(example-J'@200'caul 2@ Keel) ' constmction t0 the following:
10.Static Water level belowrep of easing: 28 - . (ft,) Division of Water Resources,InfrnmutianPmcessing Unit,
If water level Is above easing;Cue"+" 1617 Mats Srrs•ice Center,Raleigh,NC 27699-1617
11;Borehole diameter:8.25" (In,) Vb.Fear Infection Wetlq ONLY: In addition to sending the fonu to the address in
Zia above.also submit a copy of tins font:within 30'days'of completion of well
12.Well construction method:Auger consimctiou to the following:
(ie.auger...rotary,cable.direct push etc.} • • ,Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Matti Service Center,Raleigh,NC 27699-1636
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13;t Yield(gem) Method of test: 24e.For Water Sootily.Srinjcctlon Welts: .
Also submit one copy of this form-wcithin 30 daysof completion of
13b.Disinfection types Amount: - well construction to the county health department of the county where
constructed. j
Form GW-t Nonh Carolina Ikperti[ent of Environment and Natural Resources—Divsston of WaterRmotrers Revised August 20l3