GW1--03490_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 14.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 well)OR LINER(if ap livable)
FROM TO DIAMETER THICKNESS MATERIAL
Regional Probing Services ft. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)
FROM , TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 10 ft. 2 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 THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 10 ft 25 tt. 2 in' .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROU
T
FROM TO NATERIAI. EMPL.'(EMENT M E1101)&:% MOt'VI
❑Irrigation 0 ft' 3 ft. Cement pour
Non-Water Supply Well:
ft
3 ft. •@Monitoring ❑Recovery 8Bentonite pour
Injection Well: ft. ft.
17 Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Storage and Recovery ❑Salinity Barrier 8 ft' 25 ft. #2 sand prepack/pour
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 25 fr. Red-Brown silt,clay and Sand
4.Date Well(s)Completed:
5/7/2024 MW-1A ft. ft.
ft. ft .......... _
5.Well Location: ft. ft. cam- s+ S I,V `�,,1
r\ `J
Peters Creek Family Fare/BP#375
ft. ft. 11 I 1 1 2>&2 4
Facility/Owner Name Facility iI N(if applicable)
ft. ft.
601 N. Peters Creek Parkway, Winston-Salem ft. ft. - _•. . ��,.t
Physical Address,City,and Zip 21.REMARKS _ VI'Y`'
Forsyth
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: , ,
(if well field,one lat/long is sufficient)
36.084047 N 80.25717 W Lawrence Opper: . .
°""k"""�
"' 6 5/14/2024
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or iSA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: DYes or ElNo 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 wel I
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same 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 all depths if different(example-3@200'and 2@100') 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: 3'75 (in.) 24b. For Infection Wells: In addition to sending the form to the address in 24a
Geo robe DPT 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 Supply&Geothermal Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
136.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013