GW1-2022-05402_Well Construction - GW1_20220311

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JACOB MESSICK 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 4252
ft. ft. i
NC Well Contactor Certification Number `15.OUTER CASING for multi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
fr. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) 0.0 ft- 20.0 ft- 2.0 in- SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 20.0 rr. 35.0 ft- 2.0 in
.010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 fr' 16.0 ft' PORTLANDBENTONITE SLURRY
OMonitoring ❑Recovery ft, ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/CRA VEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 18.0 fr• 35.0 fr• 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control tr. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets itnecessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM I TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
0.0 ft- 20.0 ft• BROWN/TAN SILT
4.Date Well(s)Completed: 02/24/22 Well ID# MW-6 20.0 ft- 35.0. f- TAN SILT
Sa.Well Location:
ft. ft.
BOULEVARD CLEANERS ft. ft.
-- tr. rr.
-- Facility/Owner Name - FacilityID#(if applicable) � 1
1510 EAST DIXON BOULEVARD SHELBY 28152 rr. ft-
Physical Address,City,and Zip
rt. ft.
CLEVELAND 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL- 16.0-18.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
350 16' 22.79" N 810 30' 50.46" w A_"6 lj �r�r 03/01/22
6.Is(are)the well(s): Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,/hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or [!5No 15A NCAC 02C.0I00 or I5A NCAC 01C.0100 Well Construction Standards and that a copy
If this is a repair,.ill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under fill remarks section or on the hack ofthis form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the salve You may use the back of this page to provide additional well construction info
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 35.0 (ft.)
For multiple wells list a//depths ifdii ferent(example-3@200'and 1 n 100') Submit this GW-1 within 30 days of well completion per the following:
22.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617'MSC,Raleigh,NC 27699-1617
//hater level is above casing,use
11.Borehole diameter: 8.0 (in.) 24b. For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing°over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018