GW1--05335_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. 32.5 ft- PWR
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
IETFROM TO DIAMETER THICKNESS 1 MATERIAL
ft ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UDC,County,State,Variance,etc.) 0 ft 17.5 ft• 2 in. Sch4O PVC
3.Well Use(check well use): ft. ft in.
17.SCREEN
Water Supply Well:
pply FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural °Municipal/Public 17.5 ft. 32.5 ft- 2 in. 0.010 Sch40 PVC prepacked
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industrial/Commercial ID Residential Water Supply(shared) IS.GROUT
Irrigation FROM TO MATERIAL EMPI '(F'I ENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 3 ft. concrete pour
x Monitoring 0 Recovery 3 ft• 15 ft- bentonite pour
Injection Well:
ft. ft.
Aquifer Recharge 0 Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recover El Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [JStormwater Drainage 15 ft• 32.5 ft• #2 silica sand pour
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) QOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiVrock hype,grain sae,etc.)
ft. ' ft. See Consultant's log
4.Date Well(s)Completed:8/29/2024 well ID#MW-6 ft. ft.
5a.Well Location: R. ft. 1 j``s e-p l "`,'
Paisley Middle School fL ft. I `.• 'f et D
Facility/Owner Name Facility ID#(if applicable) ft. ft. S E P 0 6 2024
1394 Thurmond St, Winston-Salem, 27105 ft. . ft. I f
Physical Address.City,and Zip ft. ft. r11fIr1.�s-
Forsyth 21.REMARKS `�'��*�v����Jfi
County Parcel Identification No.(PIN) Flush 3urfacc compaction.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
36.114363 N -80.260197 w
7/ / fttao, 8/30/2024
6.Is(are)the well(s)0Permanent or Temporary Signature of Certifi ell 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 E3 No with ISA NCAC 02C.0I00 or/5A 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 n2/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: 32.5 (ft) 24a. For All Wells: Submit this.form within 30 days of completion of well
For multiple wells list all depths if di ferent(example-3@200'and 2@/00') 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 Iniection 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 SUDDIV& Iniection 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-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016