GW1--05334_Well Construction - GW1_20240906

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Mike Tynan 14.WATER ZONES
Well Contractor Name FROM TO , DESCRIPTION
2725-A 26 ft. 34 ft. PWR
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap Iicable)
IETFROM TO DIAMETER THICKNESS 1 MATERIAL
ft. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. (IIC,County,State, Variance,etc.) 0 ft. 19 ft. 2 in. Sch40 PVC
3.Well Use(check well use): ft. ft. '"•
Water Supply Well: 17.SCREEN
pp y FROM _ TO DIAMETER i SLOT SIZE THICKNESS MATERAAI.
Agricultural IDMunicipal/Public 19 ft' 34 ft• 2 r"' 0.010 Sch40 PVC prepacked
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft. in,
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT?IETHOD&AMOUNT
Non-Water Supply Well: 0 ft. 3 ft• concrete pour
X Monitoring 0Recovery 3 ft. 17 ft• bentonite pour
Injection Well:
ft. ft.
Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ❑Stormwater Drainage 17 ft* 34 ft. #2 silica sand pour
Experimental Technology QSubsidence Control ft. ft.
Geothermal(Closed Loop) pTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) []Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soilJrock type.gain size.etc.)
ft. ff• See Consultants log
8/29/2024 MW-5 ft. ft.
4.Date Well(s)Completed: Well ID# _
ft. ft. s..- .......♦C:s t
5a.Well Location: . N 1"...
Paisley Middle School ft. ft.
I and is(inner Name Facility ID#(if applicable)
ft. SEP 06 2024
1394 Thurmond St, Winston-Salem, 27105 ft. ft. MOST WIdien Prrr:s04;:4 unit
Physical Address,City,and Zip ft. fL 'OVOG
Forsyth 21.REMARKS
County Parcel Identification No.(PIN) Flush surface completion.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
36.114663 N -80.260143 W
8/30/2024
6.Is(are)the well(s)JPermanent or Temporary Signature of Cert d :II Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: °Yes or ONo with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#2/remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 34 (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@I00) construction to the following:
10.Static water level below top of casing:-26 (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:4 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
air rotary above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c. For Water Sunoly& Injection 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 type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016