GW1--03398_Well Construction - GW1_20240610

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Lawrence D. Opper FR.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
NC3322-A ft. ft. -
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
FROM It) DIAMETER THICKNESS MATERIAL
Regional Probing Services ft. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)
WM0401526 FROM Ti) DIAMETER THICKNESS MATFRI\I
2.Well Construction Permit#: 0 ft- 15 ft" 1 in" sch 40 PVC
List all applicable well construction permits(i.e.County,State,Variance,etc.) -- -
ft. ft. in.
3.Well Use(check well use): 17.SCREEN -
Water Supply Well: FROM TO DIAMETER SLOT SIZE I THICKNESS MATERI.Al.
❑Agricultural ❑Municipal/Public 15 ft. 25 ft. 1 in' _ .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. n• L
❑Industrial/Commercial ❑Residential Water Supply(shared) ts.GROUT
FROM TO NIATERIA1, EMPLACEMENT METHOD&AMOUNT
El Irrigation ft. ft.
Non-Water Supply Well: --
❑Monitoring ❑Recovery 0 ft• 13 h• bentonite pour
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicab
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 13 ft- 25 ft' #2 sand pour
❑Aquifer Test ❑Stormwater Drainage - -
ft. ft.
❑Experimental Technology 0 Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DE:SCRIP1 ION(color,hardness,soilhnck type.grain size.etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 25 ft. Silty Clay over Silty Sand
4/23/2024 ft. ft.
4.Date Well(s)Completed: ...
5.Well Location: ft. ft.
t.i L-V f J is.hi'•r
Speedway 6930 ft. ft. J U N 1 0 424
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
3715 Peters Creek Parkway, Winston-Salem ft. ft. h4e,fR' ��'alcr ,^tom+,:U111
Physical Address,City,and Zip
21.REMARKS _
Forsyth TMW-1,TMW-2, TMW-3,TMW-4
County Parcel Identification No.(PIN) Temporary w Ils- bandoned the same day.
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one tat/long is sufficient)
.9...,si bylaw,ence 000e,
36.020579 N 80.260370 W Lawrence Opper «"a; e°'°e`°"e4°"a'°`° ngSe-Ke,. 5/10/2024
rr.1015 533-04,3d c-Us
Oaie�]0N.05.101535:33 04W
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ❑Permanent or ETemporary By signing this form,1 hereby cent that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or/5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or EINo copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back 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
8.Number of wells constructed: 4 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the SOME construction,you can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: 25 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list al/depths if different(example-3@200'and 2@!00') construction to the following:
10.Static water level below top of casing: approx 15 (ft) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+.. 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2'25n (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Geo robe above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: p construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Simply&Geothermal 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 Amount: completion of well construction to the county health department of the county
ty� where constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013