GW1-2021-00295_Well Construction - GW1_20210127

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.Well Contractor Information:
JACOB MESSICK 14.WATER ZONES
Nell Contractor Name EROAI TO DESCRIPTION
A - 4252 rt rl
ft. D.
NV Well Contra.,Ccirafie.u.n Number 15.OUTER CASING for mul0-cued wells OR LINER if a lirahle
GEOLOGIC EXPLORATION FROM TO DIA.N ETER TtICKNF55 MATERIAL
n. n. in,
company Name
16.INNER CASING OR TUBING eothermal rimed-too
2.Well Construction Permit#: FROM TO DIA5ifTER THICKNESSI MATERIAL
„rou apph.ome lreu......I'.ar,a„perm,...or,I/I<',eaa„ry�.Score. For,oas N.ear/ 0.0 n. 5.0 fL 2.0 in. SCH 40 PVC
3.Well Use(checkwell use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM I TO DIA%I ET $IAT SIZE THICK..N FSS sATERIAL
[]Agricultural ❑Munici al/Public
P 5.0 fit' 30.0 fit' 2.0 .010 SC
40 PVC
❑Geothermal(Ileating/Cooling Supply) ❑Residential Water Supply(single) ft. R I
n.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑lRl ation ❑WeBS> 100,000 GPD FROM 1 TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft 2.0 fa POarIAND B¢NTONme SLURRY
OMonitoring ❑Recovery fit. D.
Injection Well:
fl.
[]Aquifer Recharge Groundwater Remedialion
19.SAND/GRAVEL PACK ifs lieable
❑Ayuifer Storage and Recovery ❑Salinity BarrierFROM TO MATERIAL EMPLACEMENTMETNH D
❑Aquifer Test ❑Stormwater Drainage 4.0 tI 30.0 fL 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control !t. n.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(arm ch additional been ifnecoui
Geothermal(Heating/Cooling Return)
TO DESCRIPTION color,banal vmtnak not. on,etc.)) ❑Other(explain under#21 Remarks) 0.0 D' 15.0 rE TAN SAND
4.Date Well(s)Completed: 01/12/21 Well ID# MW-2 15.0 D- 30.0 R' GRAY/BLACK SAND
Sa.Well Location: fit. ft.
WRIGHT CHEMICAL ft. rL
Pocdin^Owner Name f cilitl II).cif applicable) ft. G.
333 NEILS EDDY ROAD RIEGELWOOD 28456 D. ft.
Physical Address,Ca ,and Zip ft. fL
COLUMBUS 21.REMARKS
County Parcel Identification No.(PIN) BENTOFBTE SEAL- 2.0-4.0 FT
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if,ell field,one lal/long o sa0icient) 22.Certification:
340 19' 36.64" N. 780 12' 04.70" W A06olus'a" 1/15/2021
6.Is(are)the well(s): CEPermanent or OTemporary Signature of(enified Well Contracmr Date
B. ....... da,f,or,l herehE ,,aJb 11.1 he melt(,)Isar(were)aonrvuueJm araunlorsc irnh
7. Is this a repair to an existing well: ❑Yes or MNo /Sd S('d( 02('.0/00 or lid MA('02C 0200 H'e/l Co.utnnnon S1..Word.and rhm o enpr
It due rr o repai,ldl oo.Bnua'n veil eomro-uurnn inf<vmoun,,and rxplanr Iho mmure nfthe 4 da,roeard hoe ham p,n sled e,die Ive//uu-,lee
relxnr under 21 renlnrkr xenon nr o.r the hark of 11.../!nn
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal W ells having the same You may use the back of this page to provide additional well construction Into
construction,only I GW-I is needed_ Indicate TOTAL NUMBER ofwells (A4d'See Oter'in Remarks Bost You mac also attach additional pages it neccssun.
drllcd'. q 'j 1
CI F �, y 4.SUBMITTAL INSTRUCTIONS
a '
9.Total well depth below land surface: 30.0
I....nalnplo met/,ho o/l depder pJJ)erem/•.eorap/e-Jg r00'ond 2c,J/D0') Submit this CW-1 within 30 days of well completion per the following:
10.Static water level below top ofensing: 1 5.0 (fit) 249. For All Wells: Original form to Division of Water Resources (DWR),
11 nmer/erel Ir ohore coeu,g,are"-" Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 8.0 (in.) 24b. For Injection Wells: Copy to DWR, Underground Injection Control MCI
Program. 1636 MSC.Raleigh,NC 27699-1636
12.W'ell construction method: AUGER
24e,For Water Supply and department Geothermal Return tailed:Qtp}'to the
1 i.e.auger rotary,cable,direct push.etc 1 counts environmental health department of the county'where installed
FOR WATER SUPPI A'WELLS ONLY: 24d. For Water Wells producing over 100,000 GPD: Copy to DWR.CCPCUA
I}a.field(gpm) Method of test: Permit Program, 1611 MSC.Raleigh,NC 27699-161 I
13b.Disinfection type: Amount:
Form G W-I Nonh Carolina Dcparnnau of P.nvironmmiital Quality-Divistop of Water Resources Rcvired 6-6-2018