GW1--04929_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 DESCRIPTION
Well Contractor Name 24 ft. 59 ft. wet
2973A ft. ft.
Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL.
2.Well Construction Permit#: 0 ft. 39 ft• 2 1n• 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 DI:\METER SLOT SIZE THICKNESS MATERIAL
['Agricultural ❑Municipal/Public 39 ft. 59 ft. 2 '"' .010 sch40 pvc
ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ['Residential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 35 ft- Portland Cem Tremie
Non-Water Supply Well:
OMonitoring ['Recovery35 ft• 37 ft• Bentonite Chi! Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applialble)
FROM TO ! V.CIF:RI U. EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 37 ft. 59 ft
❑AquiferTest ❑StormwaterDrainage ft. ft. #1 Sand Tremie
ft.
['Experimental Technology ❑Subsidence Control
-
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color.hardness.soil/rock type.grain size.etc.)
❑Geothermal(Heating/Cooling Return) ['Other(explain under#21 Remarks) ft. ft.
6-28-24 AMW-4 ft. ft. (
4.Date Well(s)Completed: NN 01 I D# ft. ft. k •r,_,v,.r .; '
W
5a.Well Location: ft. ft. AUGe (�'A
GFL Highpoint C&D Processing Facility and Landfill A U G 1 2O 4.
ft. ft.
Facility/Owner Name Facility ID#(if applicable) :q,._..:,
ft. ft. 1' '; '4.' i. . +r•+,i:::,s 1jp.'t,
5830 Riverdale Drive, Jamestown ft. ft.
I'hs sical Address,City,and Zip 21.REMARKS
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)
35.948878 N -79.926894 w `'\ �� 10 \(.4-k-� 7./.- • aY
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with I5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo 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: 1 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: 59 (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@l00) construction to the following:
10.Static water level below top of casing: 24 (ft,) Division of Water Resources,Information Processing Unit,
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
HSA /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
13a.Yield(gpm) 24c.For Water Supply&Injection Wells:
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