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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
CARL CARPENTER 14.WATER ZONES 1
FROM TO DESCRIPTION.
Well Contractor Name ft. ft.
A - 4475
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for Multi-cased wells)OR LINER(if apQlicable)
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.UIC,County,Stale,Variance,etc.) 0.0 ft• 23.0 ft• 2.0 in' 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 23.0 ft* 38.0 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 EMPLACEM ENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft• 18.0 ft• PORTLAND BENTONITE SLURRY
1Monitoring ❑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 21.0 ft. 38.0 ft• 20-40 FINE SILICA SAND
DExperimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) OTracer 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• 10.0 ft• RED CLAY
4.Date Well(s)Completed: 12/09/21 Well ID# PZ-306 10.0 ft. 20.0 ft• BROWN SILTY CLAY
5a.Well Location: 20.0 ft• 30.0 ft* s
GRAY SAND
HANES MILL LANDFILL 30.0 ft. 38.0 ft• PWR/ROCK
Facility/Owner Name Facility IDti(if applicable) ft. ft.
325 WEST HANES MILL ROAD WINSTON SALEM 27105 ft. ft.
Physical Address,City,and Zip ft. ft.
FORSYTH 21.REMARKS ���p
County Parcel Identification No.(PIN) BENTONITE SEAL- 18.0-21k/ki 12O2?
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
36° 11' 22.70" N 800 17' 40.97" W 4� 12/29/21
6.Is(are)the well(s): (!Permanent or OTemporary 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 ONo l5A NCAC 02C.0100 or 15A NCAC 02C.'.0200 Well Construction Standards and that a copy
/f this is a repair,fill out known well construction information and explain the nature glaze. 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Ove?in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
38.0
9.Total well depth below land surface: (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3 t@200'and 2@I00')
10.Static water level below top of casing: 27.0 (ft') Information
For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If hater level is above casing,use"+" i
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
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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:
Fonn G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018