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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: j
CARL CARPENTER 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
tt. ft.
A - 4475 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if appIlicable)
GEOLOGIC EXPLORATION FROM TO DIAMETER! THICKNESS I MATERIAL
ft. ft. iin.
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.UIC,County,Sate,Variance,etc.) 0.0 ft• 15.0 ft. 2.0 t"' SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 15.0 ft• 30.0 ft. 2.0 in' I .010 SCH 40 PVC
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO , MATERIAL EMPLACEM ENT M ETHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 10.0 ft. PORTLAND BENTONITE SLURRY
OMonitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation ' i
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 13.0 ft. 30.0 ft. 20-40' FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
OGeothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
0.0 ft• 10.0 ft• RED CLAY
4.Date Well(s)Completed: 12/07/21 Well ID# MW-25S 10.0 ft. 20.0 ft' BROWN SILTY CLAY
5a.Well Location: 20.0 ft* 30.0 ft.
TAN SILTY SAND
HANES MILL LANDFILL ft. ft. I
Facility/Owner Name Facility ID#(if applicable) ft. ft. E - -
325 WEST HANES MILL ROAD WINSTON SALEM 27105 ft. ft. MAR 1 202?
Physical Address,City,and Zip ft. ft.
FORSYTH 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL•-•.10.0-13.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
36° 11' 26.51" N 80° 17' 39.30" W ``� =s- 12/29/21
6.Is(are)the well(s): Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or elNo 1SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature ofdte of this record has been provided to the well owner.
repair under fill 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 construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 30'0 (ft.)
For multiple wells list all depths ifdiiferent(example-3@.200'and 2 a@100') Submit this GW-1 within 30 days of well completion per the following:
20.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: A) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If hater level is above casing,use"+"
11.Borehole diameter 8.0 (in.) 24b. For Injection Wells:Copy to DWR,Underground Injection Control(1UC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) , Method of test:
13b.Disinfection type: _ , Amount:
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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