GW1--04927_Well Construction - GW1_20240816

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Kevin White 14.WATER ZONES
FROM TO DES(RIP I ION
Well Contractor Name ft' ft.
2973A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi cased wells)OR LINER(if applicabk)
FROM TO DIAMETER THICKNESS h MATERIAL
Parratt-Wolff, Inc. o ft. 43 ft' 4 in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIA IEEE:R THICKNESS MATERIAL
2.Well Construction Permit#: 43 ft. 53 ft• ;4 in. sch40 pvc
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS NIA IE:RIAL
❑Agricultural ❑Municipal/Public 53 ft. 63 ft. 2 '"' 010 sch40 pvc
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 49 rc Portland Cem Tremie
\on-Water Supply Well:
'A Monitoring ❑Recovery 49 ft. 51 ft- Bentonite Chil Tremie
Injection Well: rt. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MAIERIAI. FM PLACE 1 ENT ME:71101)
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
51 63 #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage -
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO r DE:SCR IP LION(color.hardness,soil/rock type,grain size,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
7-3-24 AMW-5D ft. ft.
Date Well(s)Completed: IA ell am
ft. ft.
5a.Well Location: ft. ft. • , %
GFL Highpoint C&D Processing Facility and Landfill
ft. ft. AUG
Facility/Owner Name Facility ID#(if applicable) ft. ft A 1] I t; 2024
5830 Riverdale Drive, Jamestown ft. rt.
Physical Address,City,and Zip 21.REMARKS r s,,'" -,•, ,
Guilford
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
35.948425 \ 79.926506 W ��J(.6 \ r, 7, IS • , y
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or I I I etnporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02('.0/00 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or IDNO copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under-21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 63 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: unknown (ft) Division of Water Resources,Information Processing 1 nit,
If water level is above casing,use" " 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 10 (in.) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
Air Hammer 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: amount: well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013