GW1-2022-05123_Well Construction - GW1_20220531

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-eased:wells OR LINER ifa licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. is
Company Name
16.INNER CASINGOR TUBING other al closed-loop), '
2.Well Construction Permit#: FROM I TO DIAMETER THICKNESS MATERIAL
Gist all applicable well construction permits(11.e.UIC,County,State,Variance,etc.) 0.0 ft. 30.0 it. 2.0 1° SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 30.0 ft' 45.0 ft• 2.0 '"' 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 f" 26.0 ft- PORTLAND BENTONITE SLURRY
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft. ,
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
El Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
[]Aquifer Test ❑StormwaterDrainage 28.0 ft- 45.0 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) inOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soilfmck type,grain size,etc.
0.0 fl• 5.0 ft. BROWN SILTY CLAY
4.Date Well(s)Completed: 04/06/22 sell ID# PZ-6-4S 5.0 ft. 45.0 ft- BROWN/TAN SILT
5a.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-26.0-28.0 FEET
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ***PIEZOMETER***
(if well field,one Iattlong is sufficient) 22.Certification:
36e 12' 27.47" N 800 59' 24.00" W &6 Gjl� 04/21/22
6.Is(are)the well(s): Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(wECZcpluf cicdrd�r eav lh�
7.Is this a repair to an existing well: ❑Yes or ITNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well ConAYrtreti S iadafxls andVat a eppy'
Ifthis is a repair,fill out known well construction information and explain the nature ofdne ofthis record has been provided to the well owner. 1 20�y
22 repair under 921 remarks section or on the back ofthis form.
23.Site diagram or additional well details: 1
MAY 3
i �,,n,,fq�
c add'Se OYou may use the back of this page to provide additional well construction'
For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same ( e vet' n Remarks u y gal npnd
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells Reaks Bo ) You may also a4OWN M
drilled: 24.SUBMITTAL INSTRUCTIONS DA'A��FROG
9.Total well depth below land surface: 45.0
For multiple wells list all depths ijdiJjerent(example-3 a200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
35.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level Is above casing,use"+"
f Static water level below top of casing: (ft.) 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 prod ucin> over 100,000 GPD:Copy to DWR,CCPCUA
(gPm)
13a.Yield Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-16 1 1
13b.Disinfection type: Amount:
I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018