GW1-2022-05409_Well Construction - GW1_20220311

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: 1
1.Well Contractor Information: t
JACOB MESSICK 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
A - 4252 rt. ft.
B. rt. [
NC Well Contractor Certification Number `
15.OUTER CASING for multi-cased wells OR LINER ifa licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING Neothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,Slate,Variance,etc.) 0.0 rt. 15.0 ft. 2.0 in. SCH 40 J PVC
3.Well Use(check well use): ft. I ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 15.0"' 35.0 ft' 2.0 1n. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft' 10.0 rt' PORTLANDBENTONITE SLURRY
[EMonitoring ❑Recovery
Injection Well: ft. fa
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK ira licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO I MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 13.0 ft. 35.0 ft. 20-40 J FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/nick type,grain siu,etc.
0.0 ft• 20.0 ft. BROWN/TAN SILT
4.Date Well(s)Completed: 02/24/22 Well ID# MW-1 20.0 ft. 35.0 ft. TAN SILT
Sa.Well Location:
ft. ft.
BOULEVARD CLEANERS B. ft.
Facility/Owner Name Facility IDt/(if applicable) ft. ft. ` MAR 1 ?027
1510 EAST DIXON BOULEVARD SHELBY 28152 a. ft.
Physical Address,City,and Zip ft. ft.
CLEVELAN D 21.REMARKS
County Parcel Identification No.(PIN) BENTONIfE SEAL- 10.0-13.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: I �•
350 16' 22.79" N 810 30' 50.46" W 03/01/22
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this farm,1 hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ENo ISA NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the ofthis record has been provided to the well owner.
repair under 921 remarks section or on the back of this 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 I 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: 35.0 (ft.)
For multiple wells list a//depths ifdii6Weni(example-3 200'and 2 aclo0') Submit this GW-1 within 30 day
rts of well completion per the following:
10.Static water level below top of casing: 17.0 (ft) 24a. For All Wells: Original forin to Division of Water Resources (DWR),
IJlrater level is above caring,use
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
"+" i
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 i
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 I00,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources - Revised 6-6-2018