GW1-2022-06939_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-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
I.
ft. in.
Company Name
16.INNER CASING OR TUBING:(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 ft. 50.0 ft- 2.0 in. SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 50.0 ft' 65.0 ft 2.0 in- .010 SCH 40 PVC
[]Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑IndustrialtCommercial ❑Residential Water Supply(shared) 18-.-GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 46.0 it' PORTLANDBENTONITE SLURRY
❑Monitoring ❑Recovery rt. ft.
Injection Well: ft. ft.
[]Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 48.0 ft- 65.0 ft- 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING,LOG attach,additionalsheets ifnecessa
❑Geothermal(Heating(Cooling Return) C10ther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiltrock type,grain size,etc.
0.0 ft. 5.0 ft. BROWN SILTY CLAY
4,Date Well(s)Completed: 04/06/22 well ID# PZ-6-6S 5.0 ft- 65.0 ft- BROWN/TAN SILT
Sa.Well Location:
rt. ft.
WILKES COUNTY LANDFILL ft. ft. _
Facility/Owner Name Facility ID#(if applicable) ft. ft.
9219 ELKIN HIGHWAY ROARING RIVER 28669 rt. ft.
t
Physical Address,City,and Zip ft. ft. `
WILKES 21.REMARKS
County Parcel Identification No.(PIN)
BENTONITE SEAL,r 46.0;;'d$;0;
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
***PIEZOME-ftR�*'*�``',
(ifwell field,one lat/long is sufficient) 22.Certification:
360 12' 27.47" N 800 59' 24.00" W 6 04/21/22
6.Is(are)the well(s): 091'ermanent or ❑Temporary Signature ofCertiSed Well Contractor Date
By signing this form,I hereby certify that the ivell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 19NO 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature ofthe ofthis record has been provided to the well 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Ovee in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 65.0 (ft.)
For multiple wells list all depths ifdii fereni(example-3@200'and 1@I00) 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),
If ivater 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 prod ucin over 100 000 GPD: Copy to DWR CCPCUA
13a.Yield(gpm) Method of test:
Permit Program,1611 MSC,Raleigh, C 27699-1611
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018