GW1-2022-03245_Well Construction - GW1_20220314

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: (,
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1.Well Contractor Information: f
JACOB MESSICK 14.WATER ZONES t a
FROM TO DESCRIPTION
Well Contractor Name
it. ft.
A - 4252 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for rout*-cased wells OR LINER'if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. It.
I in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM. TO DIAMETER THICKNESS MATERIAL
List all applicable uvell construction permits(i.e.UIC,County,Slate,Variance,etc) 0.0 ft- 30.0 ft. 2.0 in. SCH 40 PVC
3.Well Use(check well use): ft. f`' in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 30.0"' 45.0 ft• 2.0 rn' 1 .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in•
❑Industrial/Commercial ❑Residential Water Supply(shared)
18.GROUT
❑Irri atlon ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 24.0 ft- PORTIANOBENTONITE SLURRY
TIMonitoring ❑Recovery D. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a lieable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 28.0 ft- 45.0 ft. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control R. 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,soilhock e, rain sin,etc.
0.0 ft- 10.0 ft• BROWN SILTY CLAY
4.Date Well(s)Completed: 01/1 1/22 Well ID# MW-3 10.0 ft- 45.0 ft- BROWN/TAN SILT
Sa.Well Location: ft. ft.
KIMS CLEANERS ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
250 SOUTH MAIN STREET MOORESVILLE 28115 ft. ft.
Physical Address,City,and Zip ft. ft.
IREDELL 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-24:0-28.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
350 34' 49.17" N 800 48' 54.17" WA"641w'b" 02/21/22
6.Is(are)the well(s): MPermanent or ❑Temporary Signature ofCertified Well Contractor Date
By signing(his form,l hereby certify that the rvell(s)was(here)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a cow
/f Ihi.s is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well oumer.
repair under#11 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 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: 45.0 (ft)
Far multiple wells list all depths iif'd ereni(example-3@200'and 2@100') Submit this GW-1 within 30 days;of well completion per the following:
35.0 24a. For All Wells: Original form,to Division of Water Resources (DWR),
tl Static water level below top of casing: (ft•) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
loalerlevelirabavecasing,use"+" '
IL Borehole diameter: 8.0 (in,) 24b.For Iniection 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 ofthe county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing lover 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
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13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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