GW1-2021-00294_Well Construction - GW1_20210127

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.Well Contractor Information:
JACOB MESSICK 14.WATER ZONES
Nell Contractor Nmne F0.051 TO DESCRIPTION
A - 4252 D. n.
rt. It.
\C P'ell Contractor Certification\umber
15.OUTER CASING for raalfi-eased wdls OR LINER ifa linable
GEOLOGIC EXPLORATION FROM TO DLAoI erER fit Ess xIATFaIeI,
IND.
company scone
16.INNER CASING OR T- NG eotb,rmal dosed-too
2.Well Construction Permit#: FROM TO DIN,FTF.R IHICKNFSJ MATERIAL
1,oallapphrnhle rreuoa,r..raa"I'l'ItNlo pc. tnr r„arn,store. Frnrnr....c-/ 0M.0 IN
9.0 D. 2.0 SCH 40 PVC
3.\fell Use(check well use): ft. ft. in.
\%Ater Supply Well: 17.SCREEN
FRO]I TO DIAxIF-I'F0. SLOT SIZE THICKNESS ]IA I'f R1Ah
❑Aetheratral ❑Municipal/Public 90 f. 19.0 fL 2.0 ' .010 SCH40 PVC
❑Geothermal(Hcaling/Cooling Supply) ❑Kesidential Water Supply(single) f. ft. t
n.
Clndustrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
Glingatlon ❑Wells 1100,000 GPD FROM 1 TO MATERIAL EMPLACEMEFTMETHOD&AMOGNT
Non-Water Supply Well: 0.0 . 6.0 o' POFRAND steromlTE SLURRY
OMonitoring ❑Rccovere ft. ft.
Injection Well: ft ft
❑Aquifer Recharge ❑Grourdscaler Remediation
19.SAND/GRAVEL PACK ifa lI' ble
❑Aquifer Storage and Recovery ❑$nhmty DarriCr FROM TO MATERIAL F:MPLdCE51EN'T MY:'1T1p11
❑Aquifer Test ❑Slona"ater Drainage 8.0 ft. 19.0 0' 20-40 FINE SILICA SAND
El Experimental Technology ❑Subsidence Control D. ft.
❑Geothermal(Closed Loop) Ell racer 20.DRILLING LOG ontach additional sheets if me.
❑Geothennal(Heatin Cooling Return) ❑Other(explain under#21 Remarks) FROM TUI DESCRIPTION eolur,hvdnem,miVm<k t, u,,o.)
0.0 H. 19.0 IN BROWN/TAN SILTY CLAY
A.Date\\'ells)Completed: 01/07/21 IN ell ID# MW-17 ft. f.
Sa.Well Location: ft. ft.
SPEEDWAY - 7944 n. n.
i'aeli,J.an-r iia;ne Facdin ID- '•-Ui aPP��cahlcT ft.
320 EAST 11 TH STREET SILER CITY 27344 ft. ft.
Physical Address.City.and Zip ft. R.
CHATHAM 21.REMARKS
Conroy Parcel Idcmi6cmimr No.(PIN) BENTONITE SEAL- 6.0-8.0 FT
51.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
ufwell field.one InVlona is sal ,,trio 22.Certification:
3SO 43' 58.87" N. 790 27' 51.48" W , O'°�°ti 1/15/2021
6. Is(ere)the well(s): LI•Permaoent or OTemprran. .Sianature ofCertifed oell Contractor Date
Hr„gnmg,hu yam.1 hrreh,r,nra rho.rhr ,,116)eras 6,erel canan,ned a,o<eardnnee;:arh
7.Is this a repair to an existing well: ❑Yes or MNo 154 V'('d( 02t'.0100 nr lid VAR 02('.0200 Hell('onornoi„Seummnv mu1Pom o-pi
If fiu,v,a repaie_lill uw known a ell eo,uvaenon inli,rrnnpan✓rid esplau..be en.me of AT w dn,r,,orJhN,heen pror,ded o,the yell owner.
re.....;o,dcr 21,,nark.wmm11 nr on rhr harA oI N/...torn,.
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal\\'ells having the same Neu may use the back of this pace to provide additional sell construction into
construction,only I GW-I is needed- Indicate TO'I AL NUMRLR of wells (add'See Over'in Remarks Box) You may also nitaeh additional pages ifnecessarc.
drilled: 24.St'BMII-I'AI.INSTRUCTIONS
9. 1otal well depth below land surface: 19.0 (ft.)
Id:...... le uellx a.,ell d:prhr pd,gerem ben,n,ple-31,200'nnd3^u luo') Submit this CNN-] within 30 days of well completion per the following:
3.0 24a. For All Wells: Original form to Division of Water Resources (DWR).
IQ Static water level below top of casing:If lerrl i.ahm..aore an If" Information Processing U M Unit 1617 SC',Raleigh,NC 27699-1617
:�mu
$.0 24b. For Injection Wells: Copy to DWR. Underground Iniection Control (IUCI
I L Borehole diameter: (in�l Program. 1636 MSC,Raleigh.NC 27699-1636
12.Well construction method: AUGER
o c.auger.mine cable,ifica 24c.For Water Supply and Open-Loan Geothermal Return Wells:Copy to the
y push.aa) county emuronmenlal health department of the county Mhere installed
FOR NV Al LR SFPPIA WELLS ONLI: 24d. For\\rater Wells need ucinE ore,I00 000 GPD:Copy to DW'R.CCPCUA
Penml Program, lot I MSC.Raleigh,NC 27699-lot I
13a.\'field(gpm) Method of test:
I3b.Disinfection type: Amount:
Form GN'-I Nunh Carolina Depnrnnent of LmUonme;nal Ounlit.-Di%lion of"ter Resources Revised 6-6-2/118