GW1--04926_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 FROM
FROM TO DESCRIPTION
Well Contractor Name 32 ft• 50 it wet
2973A e. ft.
NC Well Contractor Certification Number15.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 "LA RI.AL
2.Well Construction Permit#: 0 ft- 46 ft. 2 in. sch40 pvC
List all applicable well permits(i.e.County,Stare,Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESSMATE:RIAI.
❑Agricultural ❑Municipal/Public 36 ft. 50 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 32 it Portland Cem Tremie
Non-Water Supply Well: -
0Monitoring ❑Recovery 32 fL 34 ft Bentonite Chil Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATFRIAI. EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
34 tt 50 ft. #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control 20.DRIlilditional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DES(RIP THIN(color.hardness.soil/rock I,pc.grain sire.cic.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft
6-29-24 AMW-3 ft. rt.
4.Date Well(s)Completed: Well ID#
ft. ft
5a.Well Location: ft. +.., ,a iI I
ft.
GEL Highpoint C&D Processing Facility and Landfill AU(, 1 r ZO 24
ft. ft V 1 C
Facility/Owner Name Facility ID#(if applicable)
ft. ft. In':;; ?--,...
5830 Riverdale Drive. Jamestown ft. ft. LN:,r'• ,i-'`� 'Jt?;
Physical Address,City,and Zip 21.REMARKS
Guilford :3 x 3 pad
County Parcel Identification No.(PIN)
4"Pro Cover
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
35.952427 -79.924467 w ki. I(vs l.:A\- 7 . / • a(7/
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certi that the well(s)was(were)constructed in accordance
with 1SA NC'AC 02C.0100 or ISA N(AC 02('.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: 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: 50 (f.) 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: 37 (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 lniection 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 m Method of test: 24c.For Water Supply&Injection Wells:
(gP ) 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-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013