GW1-2022-05119_Well Construction - GW1_20220531

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JACOB MESSICK 14,.WATERZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 4252
ft. ft. '
NC Well Contractor Certification Number 15.OUTER CASING for mulft-cased wells OR.LINER'tf a ticable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKINESS MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop).
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL,
List all applicable ivell construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 ft. 5.0 ft- 2.0 in. SCH 40 PVC
3.Well Use(check well use): ft• ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLAT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaVPublic 5.0 ft 20.0 ft. 2.0 in. .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 TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 It. 2.0 ft. PORTLANDBENTONRE SLURRY
INMonitoring ❑Recovery ft. ft.
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT MErHOD
❑Aquifer Test ❑Stormwater Drainage 3.0 ft. 20.0 ft. 20-40 FINE SILICA SAND
El Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets ifnecessa
❑Geothermal(Heating(Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil(rock type,grain size,etc.
0.0 ft. 5.0 ft. BROWN SILTY CLAY
4.Date Well(s)Completed: 04/04/22 Well ID# MW-32 5.0 it. 20.0 fL BROWN/TAN SILT
Sa.Well Location:
ft. ft.
WILKES COUNTY LANDFILL ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
9219 ELKIN HIGHWAY ROARING RIVER 28669 ft. ft.
Physical Address,City,and Zip ft. ft.
WILKES 21.REMARKS.; -
County Parcel Identification No.(PIN) BENTONITE SEAL-2.0-3.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ha/long is sufficient) 22.Certification:
360 12' 27.47" N 800 59' 24.00" W 04/21/22
6.Is(are)the well(s): [EPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,]hereby certify that the svell(s)ivas(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ITNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well tali
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. 0t� Y'
repair under#21 remarks section or on the back ofthis form.
23.Site diagram or additional well details: �p�V�/ � )JUL8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additt1A 1 v, 1 on n info
construction,only I GW-i is needed. Indicate TOTAL NUMBER of wells (add'See Ovet'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS 1n40T aSai1 Pf`tt 'lAg Unr
20.0 DVIMMOG
9.Total well depth below land surface: (ft.)
For multiple wells list all depths ifd fferent(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: 8.0 (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ijsvater 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 DWI?,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 27699-1 61 1
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018