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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
CARL CARPENTER 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
A - 4475
ft. ft. i
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
GEOLOGIC EXPLORATION FROM 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.U/C,County,State,Variance,etc.) 0.0 ft• 'MO.0 ft 2.0 in' SCH 40 PVC
3.Well Use(check well use): ft. ft.17.SC
in.
Water Supply Well: FROM REE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 11.0 ft* 21.0 ft' 2,0 in' .010 SCH 40 PVC
OGeothermal(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' 6.0 ft. pORTLANDBENTONITE SLURRY
lMonitoring ❑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 9.0 ft. 21.0 ft• 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
OGeothermal(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 ft• RED/BROWN SILTY CLAY
4.Date Well(s)Completed: 11/17/21 Well ID# PZ-304 10.0 ft. 21.0 ft' GRAY SILTY SAND
ft. ft.
5a.Well Location:
HANES MILL LANDFILL ft. ft.
Facility/Owner Name Facility 1Db(if applicable) ft. ft. 1
325 WEST HANES MILL ROAD WINSTON SALEM 27105 ft. ft. MAR 1 it 2022
Physical Address,City,and Zip ft. ft.
FORSYTH 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL'6.0,.-.9.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
36° 11' 18.87" N 80° 17' 49.66" W t � -1,
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 ENo 15A NCAC 02C.0/00 or l5A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a 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 H21 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 I 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: 21'0 (ft.)
For multiple wells list al/depths if different(example-3 a 00'and 2«l00') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 1 5.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
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 OpenLLoop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
I
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
13b.Disinfection type: Amount:__
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018