GW1-2022-05122_Well Construction - GW1_20220531

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JACOB MESSICK 1a.wATERzoEs ,�
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 4252
ft. ft.
NC Well Contractor Certification Number As.OUTER CASING`formula,-cased wells'OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft,
ft. in.
Company Name
16ANNER CASING OR TUBING "edthermal closed-Io6
2.Well Construction Permit#: FROM I TO DIAMETER THICKNESS MATERIAL
List all applicable ivell construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 ft. 28.0 fi- 2.0 1O SCH 40 PVC
3.Well Use(check well use): ft. I ft. in.
Water Supply Well: 17 SCREEN `°`9
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 28.0"' 43.0 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 "
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 It- 24.0 ft' PORTIAND BENTONDE SLURRY
IMMonitoring ❑Recovery ft. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
ti 19.SAND/GRAVEL
ft.
PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 26.0 ft, 43.0 ft- 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)-
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rocktype rain she,etc.
0.0 ft• 5.0 ft. BROWN SILTY CLAY
4.Date Well(s)Completed: 04/05/22 sell ID# MW-30 5.0 ft- 43.0 ft- 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-24.0-26.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IatAong is sufficient) 22.Certification-
360 12' 27.47" N 800 59' 24.00" W 04/21/22
6.Is(are)the well(s): ITPermanent or ❑Temporary Signature of Certified Well Contractor Date
13y signing this form,I hereby certify that the wells)1T C8(}3RFIi B ,P c� J with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 We n c n rMAr at737h Ta copy
Ifthis is a repair,fill out knoivn well construction information and explain the nature of the of this record has been provided to the ivell owner. (�
repair under 121 remarks section or on the back ofthis form. MAY 3 1 2072
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 FIRA ,,. rQrl�r fo
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may s( � t� > �es Neccessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 43.0 (ft.)
For multiple wells list all depths ifdifferent(example-3@200'and 2@1003 Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 20.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+^If Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 8.0 (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(MC)
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 100,0"GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC
13a.Yield(gpm) Method of test: 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