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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
CARL CARPENTER
14.WATER ZONES i a
Well Contractor Name FROM TO DESCRIPTION
ft. ft. I
A - 4475 ft. ft. II
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.UIC,County,State,Variance,etc.) 0.0 ft- 2.0 ft• 2.0 j in* SCH 40 PVC
3.Well Use(check well use): R. ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE _ THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 2.0 ft• 17.0 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 EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft• 1.0 ft. PORTLANDBENTONITE 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 1.5 ft• 17.0 ft 20-40 FINE SILICA SAND
❑Experimental 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) lOther(explain under#21 Remarks)
0.0 ft• 5.0 ft• BROWN SILTY SAND
4.Date Well(s)Completed: 12/17/21 Well ID# LFG-25 5.0 ft• 17.0 it PWR/ROCK
ft. ft.
5a.Well Location:
GFL LANDFILL ft. ft.
Facility/Owner Name - Facility ID#(if applicable) ft. ft.
5830 RIVERDALE ROAD JAMESTOWN 27282 ft. ft. MAR 1 7O2?
ft. ft.
Physical Address,City,and Zip
GUILFORD 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL - 1,0-1.5 FEET
***GAS PROBE***
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35° 57' 09.32" N 79° 55' 22.15" W � 'G--,:)- 12/29/21
6.Is(are)the well(s): OPermanent 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 ElNo 15A NCAC 02C.0100 or 15A 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#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 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: 17'0 (ft.)
For multiple wells list all depths ifdifferent(example-3(200'and 2@100') Submit this GW-1 within 30 dayS'of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
IL 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
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: 1
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018