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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
tt. 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. j 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,State,Variance,etc.) 0.0 ft. 31.0 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 31.0 ft' 46.0 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) q8.GROUT
❑Irrigation ❑Wells> 100,000 GPD FROM . TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft' 26.0 ft' PORTLANDBENTONITE SLURRY
IBMonitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19:SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO . MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 29.0 ft• 46.0 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- 10.0 ft' RED CLAY
4.Date Well(s)Completed: 1 1/29/21 Well ID# PZ-307 10.0 ft' 20.0 ft- BROWN SILTY CLAY
5a.Well Location: 20.0 ft- 35.0 ft' GRAY SAND
HANES MILL LANDFILL 35.0 ft- 46.0 ft. PWR/ROCK
Facility/Owner Name Facility ID#(if applicable) ft. ft. '325 WEST HANES MILL ROAD WINSTON SALEM 27105 ft. ft. MAR I , 2021
Physical Address,City,and Zip ft. ft.
FO RSYT H 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-26.0-29.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
36° 11' 25.32" N 80° 17' 46.20" W . % =- 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 FENo 15A 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#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 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: 46'0 (ft.)
For multiple wells list all depths if different(example-3 a 00'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below of casing: 35.0 (ft) 24a. For All Wells: Original foi-m to Division of Water Resources (DWR),
10.Stater tic el is above casing,use top Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 8.0 (in.) 24b. For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 276'99-1636
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 27699-1 61 1
13a.Yield(gpm) Method of test: i
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources ' Revised 6-6-2018
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