GW1--01292_Well Construction - GW1_20240229

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• WELL CONSTRUCTION RECORD For.Ittletna1Usepticif.: I •
This form can be used foiiingle at multiple wells•
1.Well pintractur InfOrniation:
.14:WATER ZON ES
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Stefan Smith - tr120.M. TO DESCRIPTION
Well Colatactot Noma, ft: ft.. I
3576A . .
NC Well Contract&Ceriifteatioli Neat& 45,00TER CASING d'or muill:easedtills1 OR LINER area Eliable1.
•FROM -TO , ' DIAMETER•-• THICS;N.fsS•SAEDACCO MATERIAL-
° ft.. 20 ft. 2 I to. SCH-40 . PVC
Company.Manic- ' ' 16.INNERCASING OR TUBING(geothermal ellased4oep).•
-FROM TO MAMETER . TIIICEOWSS MATERIAL
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2.WOI*C011017,161011 Permit 4: . . .. ' • -R. ft; ' 'ht.
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,Litroflagilictildettellpeitnitsfix.County:jam;,Varianw,friecticrt or.).
' rt.
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3.Welt tisi(cheek.WA lise): 11 S(
. .THOM% . TO •OtAittETER ' s LOT Siff. THIC/OOSS 1 IIATIOitat.
Water Supply Welk• -
. . . .. _ ., . . . . • ' 2 0 ft 30. R. 2 lo, ' '.010 ' SCH40 PVC
.bAgtfeultinal - OhluniapallPublie• .
12
ff. . ..i ,Geothermal(Heatingtooling Supply) OResideutial Water Supply(single) - _ft. o.
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0' GR . . - . -
ID lodostrialfamuntercial CiResidential Water Supply,(skated) UT
FROM. - TO . %MATER/AL . EMPLACEMENT-METHOD&A11011INT
Clinigation• . . 0 ' It.- '16 ' ft. Portland Pour
Non-Water Supply Welk • .
' ff.Monitoring . . .bliCCOMY .Injection Welt:- • • ' . .
ciikquifeirlteetikei . Eidietukt0ittcr itettiectiiition. ‘IS:SAND/GRAVEL PACK(if appliratlid
• . .•..-- .. 414011- • '10" ' - MATFIRLAt. • F.NIPLACEA/ENT METHOD
IDAiptiferStimigi and Rceovettr' EiSalionYDarrier 18 IL 30 ft. Sand ! 2,... ._ . .
13 AquifeiTcst• . ElSlownivaier Oraiiiegc_
-0. fi.
ElESperimental'I-eclat-m(0a 17.1StlbfidetiCk0111411. ... .. .. . .. . : . ... ., . . _ .
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'211:DRILLING'LOG:Inilach additioriekbeelsif-nceeswayl I
bgeotitennal(closed Loop) • bTracer. • . FRONT 'TO ' DESCRIPTIONtivbk hardnevii torthick r_iee.eraiti etre,tie.1 I
.0 El esSolfteituat(ileatinglatolitig Return} ClOther(nnpiain under.#21 Rematis) rt. 30 it, Silt
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R i.---1.".r:.7?
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4.DateWeD(s)Coniplifed: 1-22-24 ,Wig mii It ft.
III15 -'' -4 ft • I:1 VD
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5
:I.,WidlLocaRoin ..ft. it. FEB 2 a 2074
Thruway Shopping Center • ' ' h. It. . •if*or
Facililyfflistierilente '. . Facility lud(if appliFahle) .
ft. ' "
, Wha740.0
296 S. Stratford'Rd., Winston-Salem, NC, 27103 . .ft. - ft. . • .
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PksIa'al AiIliFg.i.,City.alli iffl' ;.21.REMARKS
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Forsyth • . 2 foot bentonite sal. from,16 to 18 feet.
GAM!). . P.uvel!acute-nation NO,CPR%
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Ai,Latinsdn'and•LOngiintie iirdeireelimillutii4ceonds et-dcreiMil degrees. 22.Certifitation::
(IfWell fieldi cote latilong lasuIlleicea)
qa /54,
36.092629 ' , . IN' 80.282378' • 'W. _,..a
1, .- ' '
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" 1/2 6/2024
. Sig -.0 pf Ce,lied Well Conuottof : • .Dato
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6.Is(are)thewell(s): 10Pennintent or UTemporary .
Ity..ligning nkis fomr;i inergly certify fili2V/he WOW 13:12S(iirly)cpnyiniczed it,ace011iq2CT
- ii.0h 111 MCA C 02C.0100 or.15A NC,IC-(J2C 400 Well eonstivorcur kainfaais and that a
7.Ilthis a rePoirto ai44isting well:, EIW*- or Nino •cevii0f Mir ityfird tiOs Nen proyfdeil to'ili,e;"9.ell(poor.
If tiols'is a tip*.fill oat kathai weld canann-dod Worm:ion and rsPlahrrhe nature of the
repair under#21 ietnarks",:irciain or on the bad:of this foam 23.Site_dingram or additional well tietalts:
You.may use the back of this page to provide additional well site details or_Well
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8.Ninnberof wells constructed: 1 . CanstruCtion details. You may alto ailach•additional pages if necesSaty.
For;tftUirlile Irtfeei4m.ir qou-iyikrer supply tr:akONLY with die same cmiStruetion,you em . . .. " ..-.. -. ...
sutoiaourforia. . SURMETTAI.INSTUCTIONS. '
9..Total well depth betow laud surface:• 30 (ft) /4o.•Our All Wells: •Submit this-form within-30-days of:eomptetioli of Well
For nuilriple lids-list aff depths if dOrenl&Amer 30200'oful 26100) . eonsftuction to the following:
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10.Static water level below top of easing 17 ' .(ef.) Division of Water Resetir**,InformationProcesaing Unit,
limiter:lerells above&Wag;ate"+" . 1617'Mail Service Coifer,Raleigh,NC 27699-1617
11.Borehole diametr.r:9•25" . Iin.) • 24b.For Infection:Wcils ONLY: In addition to sending the form to the'addressin
. 24a aboye.also submit a.copy.of this Pone within 30 days of.completion*if well
12.Well construction-Method!',IPA _ . , coustiudion to the folloWitig!•
0.e.auger.roialy,eatIc.'dirF,1 rash.etc..-}.
'Division of Water Resources;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: .1636 Mali Service Center,Raleigh,NC 27699-1636
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• '24e.For Water Sapnlv&Intetion Welts:
13 Yield 000 • • Method nf teSt:
Also submit one ciapy of this farm[Within 30,dayS Of completionpf
13b.Disinfection,type; Amount: • - tr
• well:'consuction to the-county health department of the.couno,.wherc
", constMeted.
FanutOW-1 North Caren=Department of Envitunartu•ond Natural Resources-Division of Water'Rm_auTas Revised Austat2813
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