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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
CARL CARPENTER 14.WATER ZONES
Well Contractor Name FROM TO , DESCRIPTION
ft. ft.
A - 4475 ft. ft. '
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. i in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable hell construction permits(i.e.U/C,County,State,Variance,etc.) 0.0 ft• 10.0 ft. 2.0 I"' SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ID Agricultural ❑Municipal/Public 10.0 ft• 20.0 ft• 2.0 in' .010 SCH 40 PVC
❑Geothermal(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 EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft• 6.0 ft. PORTLANDBENTONITE SLURRY
IMMonitoring ❑Recovery ft. ft.
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 8.0 ft• 20.0 ft. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
DGeothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
0.0 ft• 10.0 it RED CLAY
4.Date Well(s)Completed: 11/18/21 Well ID# PZ-302 10.0 ft• 20.0 ft• BROWN/TAN SILTY SAND
5a.Well Location: ft. R.
HANES MILL LANDFILL ft. ft.
Facility/Owner Name Facility 1D4(if applicable) ft. ft. j
325 WEST HANES MILL ROAD WINSTON SALEM 27105 ft. ft.
Physical Address,City,and Zip
ft. ft. MAR 14 2029
FORSYTH 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL.-6.0 8.0 FEET
i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
36° 11' 19.33" N 80° 17' 47.00" W G:=- Za =j" 12/29/21
6.Is(are)the well(s): OPermanent 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 l No I5A NCAC 02C.0100 or 15A 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 of the 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 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: 20.0 (ft.)
For multiple wells list a/I depths if different(example-9 a 00'and lac/00') Submit this GW-1 within 30 days;of well completion per the following:
10.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: 8.0 (in.) 24b. For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
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
f
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:
Fonts GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018