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HomeMy WebLinkAbout__20220311 (18) , i 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 j 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