GW1-2022-06456_Well Construction - GW1_20220527

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-cased wells OR LINER ifa licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS 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 well construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 ft. 32.0 ft. 2.0 1n' 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 32.0 ft' 37.0 ft' 2.0 1°' 010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑IndustriaVCommercial ❑Residential Water Supply(shared) 18.GROUT
❑lrrl ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 28.0 ft' PORTLANDBENTONITE SLURRY
IMMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK ifa 6cable
[]Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 31.0 ft. 37.0 fL 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. It.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) FROM I TO DESCRIPTION color,hardness,soil/mck type,grain sire,etc.
0.0 It. 37.0 ft- RED/BROWN SILTY CLAY
4.Date Well(s)Completed: 05/13/22 Well ID# PZ-5 ft. ft.
Sa.Well Location:
ft. ft.
LAKE MICHAEL DAM ft. ft.
Facility/Owner Name Facility IDS(if applicable) ft. ft.
LAKE MICHAEL PARK ROAD MEBANE 27302 ft. ft.
Physical Address,City,and Zip ft. ft.
A LA M A N C E ,21.REMARKS
County Parcel Identification No.(PIN) BENTONIfE SEAL-28.0-31.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
360 06' 27.12" N 790 15' 02.21" W � 05/27/22
6.Is(are)the well(s): IMPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby cert fy that the ivell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or I!flNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
/f this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the ive/l owner.
repair under#21 remarks section or on the back ofthis form.
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 well construction info
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attaD d�jitional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS ✓�+9.Total well depth below land surface: 37.0 NA AV ' r't ?d�
For multiple wells list all depths ifili ferent(example-3 a200'and 2@100) (ft.) Submit this GW-1 within 30 days of well completion ellowing:
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) 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)
AUGER Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 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:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018