GW1-2022-06935_Well Construction - GW1_20220601

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 if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name _
16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM I To I DIAMETER I THICKNESS I MATERIAL
List all applicable ivell construction permits(i.e.UIC,County,State,Variance,eta) 0.0 ft- 35.0 ft 2.0 1 ' I 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 35.0 ft' 55.0 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>100,000GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 30.0 ft' PORTLAND BENTONDE SLURRY
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 33.0 ft' 55.0 ft 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) []Tracer 20.DRILLING LOG attach additi6nal'sheets if necessary),,
❑Geothermal(Heating/Cooling Return) InOther(explain under#21 Remarks) FROM To DESCRH'TION color,hardness,soil/rock type,gmin size,etc.
0.0 ft. 5.0 ft BROWN SILTY CLAY
4.Date Well(s)Completed: O4/O7/22 well ID# PZ-6-5 5•0 ft 55.0 ft- BROWN/TAN SILT
5a.Well Location: ft. ft.
WILKES COUNTY LANDFILL ft ft.
Facility/Owner Name Facility ID#(if applicable) Ct. ft•_
9219 ELKIN HIGHWAY ROARING RIVER 28669 ft. ft.
Physical Address,City,and Zip ft. ft ;'ls,, ;ii%�/n�X•i1,,v
WILKES 21.REMARKS
County Parcel Identification No.(PIN)
BENTONITE SEAL-30.0-33.0 FEET
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ***PIEZOMETER***
(if well field,one lat/long is sufficient) 22.Certification:
360 12' 27.47" N 800 59' 24.00" W 04/21/22
6.Is(are)the well(s): MPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)ivas(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or IENo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known tivell construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this 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 1 GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Ove?in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 55.0 (ft.)
For multiple wells list all depths ifdii ferent(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: 40.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
1f water 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 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 100,000 GPD:Copy to DWR,CCPCUA
(gPm)
13a.Yield Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018