GW1-2022-03246_Well Construction - GW1_20220314

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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.
NC Well Contractor Certification Number 15.OUTER CASING'for multi-cased wells OR LINER if ap licable
GEOLOGIC EXPLORATION FROM I TO DIAMETER FTHICKNESS MATERIAL
ft. tr. � in.
Company Name '
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction perntils(i.e.U1C,County,Slate,Variance,etc) 0.0 ft' 25.0 ft• 2.0 'n' SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROM
SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 25.0 ft' 40.0 ft' 2.0 'n' .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in:
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑lrrl ation ❑Wel Is>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 20.0 ft- PORTLANDBENTONLTE SLURRY
TIMonitoring ❑Recovery
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
-19.SAND/GRAVEL PACK(ifapplkable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 23.0 It- 40.0 ft. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG lattach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/mck type,grain size,etc.
0.0 ft. 10.0 ft- BROWN SILTY CLAY
4.Date Well(s)Completed: 01/13/22 .Well ID# MW-2 10.0 ft- 40.0 It- BROWNITAN SILT
5a.Well Location: ft. R.
KIMS CLEANERS fr. fr.
Facility/Owner Name Facility ID#(if applicable) ft. ft. MAR 14 2029
250 SOUTH MAIN STREET MOORESVILLE 28115
Physical Address,City,and Zip ft. ft.
IREDELL 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL- 20.0-23.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
350 34' 49.17" N 800 48' 54.17" W14*16 " 02/21/22
6.Is(are)the well(s): APermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify thapthe well(s)was(were)constructed in accordance wilh
7:Is this a repair to an existing well: ❑Yes or [!5No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
l f lhis is a repair,fill out known well construction information and explain the nature of7he gflhis record has been provided to the hell owner.
repair under#21 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: 40'0 (ft.)
p i ( Submit this GW-1 within 30 days'of well completion per the following:
(•n n r ndtip/e wells list all depths i f di event cxarep le-3 200'and 2 l(10') i
35.0 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
if waler level is above casing 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
1 AUGER
.e Well construction method: 24c.For Water Supply and Cl en(Loo m Geotheral 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 27699-1 61 1
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
t '
Form GW-I North Carolina Department of Environmental Quality-Division Of Water Resources' Revised 6-6-2018