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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. I
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. 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.U/C,County,State,Variance,etc.) 0.0 ft• 15.0 ft• 2.0 in' SCH 40 PVC
3.Well Use(check well use): ft. H. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 15.0 ft' 35.0 ft' 2.0_ 'n• .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) -- -ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
❑Irrigation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft• 11.0 ft• PORTLAND BENTONITE SLURRY
Monitoring ❑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 13.0 ft• 35.0 ft. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
0.0 ft• 1.0 ft• CONCRETE
4.Date Well(s)Completed: 02/1 1/22 Well ID# . MW-6 1.0 ft. 10.0 ft' BROWN CLAY
5a.Well Location: 10.0 ft• 20.0 ft' TAN SILT .
BAUX MOUNTAIN - 76 20.0 ft• 35.0 ft. TAN SILTY CLAY
Facility/Owner Name Facility ID#(if applicable) ft. ft. ! MAR 1 .1 202_9
4801 OLD RURAL HALL ROAD WINSTON SALEM 27105 ft. ft.
Physical Address,City,and Zip ft. ft.
FORSYTH 21.REMARKS .
County Parcel Identification No.(PIN) BENTONITE SEAL- 11.0-13.0 FEET
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
36° 09' 12.23" N 80° 13' 33.80" W -
'`� 02/18/22
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 ffflNo I5A NCAC 02C.0100 or/5A NCAC 02C.0200 Well Construction Standards and that a copy
If this isa repair,Jill out known well construction information and explain the nature of the of This record has been provided to the well owner.
repair under#21 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: 35'0 (ft.)
For multiple wells list all depths if different(example-3@200'and 2@/00') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 23.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ill rater level is above casing,use"4-"
11.Borehole diameter: 8.0 (in.) 24b. For Injection Wells: Copy to DWR,Underground Injection Control (IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
AUGER 4
12.Well construction method: 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:
i
i
13b.Disinfection type: Amount: i
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
E -