GW1-2022-05405_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 DESCRIPTIONft. ft.
A - 4252 '
ft. ft. !
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
�ft
ft. in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.VIC,County,State,Variance,etc) 0.0 ft- 15.0 ft. 2.0 in. SCH 40 PVC
3.Well Use(check well use): ft• ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 15.0 ft' 30.0 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
❑Irrl ation ❑Wel Is> 100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 10.0 ft' PORTLANDBENTONITE SLURRY
MMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 13.0 ft• 30.0 fr• 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control R. I ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) FROM I TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
0.0 fc• 15.0 ft• BROWN/TAN SILT
4.Date Wells)Completed: 02�23/22 Well ID# MW-3 15.0 ft. 30.0 ft. TAN SILT
Sa.Well Location:
ft. ft.
BOULEVARD CLEANERS ft. ft.
Facility/Owner Name Facility ID#(if app!icable) ft. ft. LUL
1510 EAST DIXON BOULEVARD SHELBY 28152 rt. ft.
Physical Address,City,and Zip ft. ft.
CLEVELAND 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL^- 10.0-13.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Willong is sufficient) 22.Certification:
350 16' 22.79" N 810 30' 50.46" W 10*16 oxp"" 03/01/22
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0/00 or 15A NCAC 02C.0100 Well Construction Standards and that a copy
IJ7his is a repair,fill out known well construction information and explain the nature ofthe ofthis record has been provided to the ivell owner.
repair under P21 remarks section or on the back ofthis form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only 1 GW-1 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: 30•0 (ft.)
For nwhiple wells list all depths iJ'dt ferent(example-3@200'and 2@100') Submit this GW-1 within 30 days'of well completion per the following:
17.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
i Static water level below top of casing: (ft. Information ProcessingUnit,1617 MSC,Raleigh,NC 27699-1617
//'water level is above caring,use"+" )
11.Borehole diameter: 8•0 (in) 24b. For Infection Wells:Copy to DWR,Underground Injection Control (IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER
(i.e.auger,rota 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
g 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
13a.Yield(gpm) Method of test:
Permit Program,1611 MSC,Raleigh,NC 27699-1611
II
13b.Disinfection type: Amount: f
f1
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resourcesl Revised 6-6-2018
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