GW1-2022-05118_Well Construction - GW1_20220531

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JACOB MESSICK 14iWATER'ZONEs:'`'
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 4252
ft. ft.
NC Well Contractor Certification Number
15.'OUTER CASING for multi-case&wills OR LINER'If a livable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. is
Company Name
16 INNER'CASING OR TUBING eothermal closed-loo,`'
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 ft- 48.0 ft- 2.0 1° 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 48.0 ft 68.0 ft' 2.0 1D• .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 ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft, 44.0 ft' PORTLANDBENTONIIE SLURRY
I!flMonitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge []Groundwater Remediation
19:SAND/GRAVEL PACK if a livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 46.0 ft' 68.0 ft- 20-40 FINE SILICA SAND
❑Experimental Technology El Subsidence Control 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,soiurock type rain sire,etc.
0.0 ft• 5.0 rt• BROWN SILTY CLAY
4.Date Well(s)Completed: 04/06/22 Well ID# MW-31 5.0 rt. 40.0 ft• BROWNITAN SILT
5a.Well Location: 40.0 ft' 68.0 ft' BROWN/TAN SILTY PWR
WILKES COUNTY LANDFILL ft. ft.
Facility/Owner Name Facility ID11(if applicable) ft. ft.
9219 ELKIN HIGHWAY ROARING RIVER 28669 ft. ft.
Physical Address,City,and Zip
ft. ft.
WILKES "11,REMARKS:.', n
County Parcel Identification No.(PIN) BENTONITE SEAL-44.0-46.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
360 12' 27.47" N 800 59' 24.00" W � y" 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 we/l(s)ivas(were)constructed in accordance ivith
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well �1i,07Nt n7a a r c py
Ifthis is a repair,fill out known well construction information and explain the nature ofthe ofthis record has been provided to the well owner. ..
repair under#21 remarks section or on the back ofthis form.
23.Site diagram or additional well details: ��,e/��I � �tl
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide addif AYI Il n AbriO n info
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages i£necessary.
drilled: 111 WWWj3'1 •Pr=502r-g ryb
24.SUBMITTAL INSTRUCTIONS u•�3t(r jt,QC
9.Total well depth below land surface: 68'0 (ft)
For multiple wells list all depths ifdierent(example-3@200'and 2@I00) 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),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use"+"
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
13a.Yield(gpm) Method of test: "GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1 11
13b.Disinfection type: Amount:
i
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018