GW1--01293_Well Construction - GW1_20240229

1
WELL CONSTRUCTION RECORD For Internalise ONLY: ' '
This form can be used for single Or multiple wells
1.Welt CDntl.tetor Information: -
LT WATER ZONES
Stefan Smith _ FROM TO DF'SCttIPlION
Well Contractor is'ame ft. It.
3576A' ft. tt:
NC.WJI Contractor CanilicatiooNtutlici :tS.OUTER CASING(for titutli-cti,ed nets)OR LINER(If up tfleabkh
FROM TO DIAMETER, THICKNESS MATERIAL
SAEDACCO 0 ft. 20 ft. 2 ht. SCH-40 PVC
Can arty Manor .16.-INNER-CASING OR TUBING(Reothermai closed-loop).
FROM TO ' DIAMETER. 7111Cti,NESS MATERIAL
`
2,Welt Construction Permit is R. ft, ,`hL
Lift onfilplic'a(rle rsrll peewits fi e.County.Sath..Variance.fryadort erc) - -
.R, ft, fn.
3.Wclt.lise(cleats ITOt usej t1:SCRtEN
Water Supply Weil: , FROM. ( TO DIAMETER SMITSlar TIIte1isM4S 1 MATERiAl.
Clrigliculttltal CIMunicipaL''Poblic 20 ft. 30 R, 2 in OSO SCH-40 PVC
OGeotltennal(licatitg,'Cooling Supply) ®Residential Water Supply(single) ft- ft. is I
©industrial/Coumtercial ElResideutlal Water Supply(sbatedi , ERo IROUT TO MATERIAL I EMPLICEMENT.MEr11OD 3 AMOUNT
lJk patiijn 0 ft. 16 ft. Portland Pour
Non-Water Supply Well:
R. f1.
Ohlonitoring glitccovcry ,
Injection Weil:, rt. ft.
CI Aqutfcr Recharge DGiounds i;cr Reincdiation . '19.SAND/GRAVEL PACK(if applicable) •
-
FROM 'TO M,TERtAI. EMPLACEMENTMErtion
fAtinifct Storagcand Recovety []Salinity Hamer 18 - R.. 30 ft. Sand 2
II Aquifer Test DStocnnmatcrDrainage ..
ft. ft. •
❑Experimenlal Technolo ' ❑Subsidence Control ,
20:DRILLING LOG'(altaed additional sheets-if-necessary)
CIGeotltemtal(Closed Loop) .DTracer .FROM TO DESCRIPTION icobr.hnNne,..wu'nicktstx.vrain Nile,dt.I
•
DGe othenual(Fleating1Cooliug Return) 17Other(explain under#21 Rereads) 0 R. 30 ft silt
ft. (L o a l��-....
4.Date Well(s)C.mnytletal 1-19-24 Well ID#mw-4 n, tL ' -ti e t.)
5a:Well Location: ft. ft. • FEB 2 9 ton
Thruway Shopping Center rt. ft,
Facility,OirncrNanc Facility IDk(ifapplwiible) R. (t. IO7`NIT:Ie'I Pr^ ;p�;E
,
296 S. Stratford Rd., Winston-Salem, NC, 27103 ft ft, ' C,rA J/&OG
Plniical Aildiess.City.and Zlp' %21..REMARKS
Forsyth 2 foot bentonite seal from 16 to 18 feet.
County Parcel ldaalifroation No.(PIN) •
51i.Latitude arid Longitude in ticgreeslminutcslscconds Or decimal degrees: 22.Ceraifieation:
(Snell field,one at/long la sufficient)
36.092449 N 80.282078 rrY ' j Al 1/26/2024
. Signs'.7ofl eilred Well Contractor Dale
6.Is(are)the well(s): %IPermattent or i7Temporary -ifj'signing this form,I frerel.}'certify tharthe welly)Intl eKr-eJ conrlructed in mxorrlanc.a
with 15A NCAC 02C.0100 or I SA NCAC 02C.0200 Well Constriction Sratufards and llxu a
7.iN this a repair to an existing well: DlYes or 1ffiNo 'ccyiraf rldr rerortf has treco firorukd ro,04 well muter.
Ifthis'&a relsilr.fill a,'lr krtaus.well consNnct lei brf0rtnadhn am!r_cpiahr the'share of-rite
repair ruiner*21 icnrarla irctiun ar on the bad of rims forme. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or Well
8.Number of wells constructed: 1 censtluction details. You may also.attacl'adtlifionat pages if=essary.
For mnhlpfe lr0'ecilotr oraoo-water ntpplr wells ONLY with the same constructlou,von ma
submit one forth. '. SUBMITTAL iNSTUCTIONS
9.'Total well dcptlt below land surface: 30 ER.) 24a. For Ab Wells: Submit this form within 30 days of completion of iielL
Farnadrlple Wells list oil depots ifdi 'rent(cxeaipte-3@2011'currl2E'WO) constntctionto the fattening:
10,Static water level below top of easing: 17 • (t'f.) Division of Water Resoui+ees,Information Processing Unit,
If water lets'l is above easRtg:ase"+" 1617 Mail Service Center,Raleigh,NC 27699-4617
11.Borehole diameter 8.25" (in.) 24b.For Infection Weill ONLY: in addition to sending the form to the address in
24a above.also submit.a copy of this form within 30 days of cotnpletiou of well
12.Well construction method:HSA consimctiot to the following: }
(le.anger.rotary,cable,direct push.etc.I !
'Division of Water Resources,Underground iaejection-Control Proe am;
FOR WATER SUPPLY WELLS ONLY: 1636 Malt Service Center.Raleigh,NC 2 7699.1636
13 r Yield(gun) Method of test: 2tc.For Water Supply&Injection Wells:
Also submit one copy of this lotus is ithin 30.days of conlpletion.of
13h.Disinfection type: Amount: well construction to the county health department of the conntv.where
conatnieted. ' I
Fonn GW-t North Carolina Dcpanntent.of 8nvitottnrrd and Natural Resources-Dick Ion of WalerRtxntttm Revised August24)13