GW1-2022-05117_Well Construction - GW1_20220531

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JACOB MESSICK 14.WATER XONES
Well Contractor Name FROM TO DESCRIPTION
A - 4252
fr. ft. I
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
I&INNER CASING OR TUBING eothermal closed-loo r
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0.0. fr. 41.0 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 41.0 ft• 61.0 ft' 2.0 in' .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. ;n
❑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 ft' 37.0 ft' PORTLAND BENTONITE SLURRY
OMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier 19.'SAND/GRAVEL PAC K ifalicableFROM TO I MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 39.0 ft. 61.0 ft. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional'sheets if necessary)
El Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiltrack e, fain size,etc.
0.0 fr• 5.0 ft. BROWN SILTY CLAY
4.Date Well(s)Completed: 04/06/22 Well ID# MW-34 5.0 ft. 40.0 fr. BROWN/TAN SILT
5a.Well Location: 40.0 ft' 61.0 ft' BROWN/TAN SILTY PWR
WILKES COUNTY LANDFILL ft. ft.
Facility/OwaerName ' Facility ID#"(ifapplicable) ft. ft.
9219 ELKIN HIGHWAY ROARING RIVER 28669 ft. fr.
Physical Address,City,and Zip ft. ft.
WILKES 21.REMARKS '
County Parcel Identification No.(PIN) BENTONITE SEAL-37.0-39.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
360 12' 27.47" N 800 59' 24.00" W 04/21/22
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the ivell(s)ivas ',,,re',-con f�"cl nc v
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well C nC 1qt t��npQ t
If this is a repair,fill out known ivell construction information and explain Cite nature of the ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis form. MAY
n�/ % 1 2022
23.Site diagram or additional well details: 'Vlhi I e) A l.'
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 Ovee in Remarks Box).You may alsol�,��1;��T1Pppg �sEfr3q
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 61.0 (ft.)
For multiple ivells list all depths ifdijferent(example-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 50.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
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
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
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Farm GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018