GW1-2021-06925_Well Construction - GW1_20210505

WELL CONSTRUCTION RECORD For Internal use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: I
JACOB MESSICK .14.WATER ZONES.
� . FROM TO DESCRIPTION
Well Contractor Name I ft. ft.
A -4252 2�21 rt. ft.
- I,9yY X
NC Well Contractor Certification Number 5.OUTER CASING for muln-cased wells OR-LINER•if a licable
GEOLOGIC EXPLORATION, INCIi{Cil�;��;ti^.91�6v���s511�0 U oM To DIAMETER THICIavEss MATERIAL
P1: r�ZiE`r�{011 rt. ft. in.
Company Name 16.INNER CASING OR TUBING eothermal tiosed-loop)
FROM TO I DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit#: 0.0 ft' 37.0 It- 2.0 in. SCH 40 PVC
List alhapplicable well construction permits(i.e.County.State,Variance,etc)
ft. fL in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM. TO DIAMETER!. .SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 37.0 ft- 47.0 ft' 2.0 1 .1 .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL 'EMPLACEMENT METHOD&AMOUNT
❑Itrl ation 0.0 ft- 30.0 ft. PORTLAND BENTONTE SLURRY
Non-Water Supply Well:
ft. ft.
OMonitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK'if a licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
34.0 ft. 47.0 ft- 20-40 FINE SILICA SAND
❑Aquifer Test ❑Stormwater Drainage
ft. rt.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG'attach additional sheets'if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness soiltrock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0.0 ft• 3.0 ft- FILL
08/31/20 MW-16D 3.0 ft' 15.0 ft• RED/BROWN SILTY SAND
4.Date Well(s)Completed: Well ID#
15.0 ft- 47.0 ft- TAN/BROWN SILTY SAND
5a.Well Location: fr. ft.
SPEEDWAY - 6959
rt. ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
2808 US HIGHWAY 70 EAST CLAYTON 27520 ft. ft.
Physical Address,City,and Zip 21:REMARKS
JOHNSTON BENTONITE SEAL FROM 30.0 TO 34.0 FEET
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)
350 40' 30.64" N 780 31' 12.84" W 09/21/20
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 15A 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 ENO cop),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:, 47'0 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii erent(example-3@200'and 2@I00') construction to the following:
10.Static water level below top of casing: 15.0 (ft) Division of Water Quality,Information Processing Unit,
Ifwater level is above casing,use"+•• 1617 Mail Service Center,Raleigh,NC 27699-1617
f
11.Borehole diameter: 8•0 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
AUGER 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 Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Sunuly&Infection Wells:.In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of 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 Quality Revised Jan.2013
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