GW1-2022-06945_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-e d;wells OR LINER ifa licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0.0 ft' 1 28.0 ft. 6.0 1D SCH 40 PVC
%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. 30.0 ft- 2.0 1°' SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17w,SCREEN.
FROM TO DIAMETER SLOT SIZE THICKNESS I"MATERIAL
❑Agricultural ❑Municipal/Public 30.0"' 35.0 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 TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 It' 26.0 It' PORTLAND BENTONITE SLURRY
INMonitoring ❑Recovery 0.0 ft. 28.0 ft. PORTLANDBENTONITE SLURRY
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
"19.SAND/GRAVEL PACK ff a" l kahle -
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD"
❑Aquifer Test ❑StormwaterDrainage 29.0 ft' 35.0 fL 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessa
[]Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiVrock type,grain size,etc.
0.0 ft' 25.0 ft- TAN SILTY SAND
4.Date Well(s)Completed: 04/27/22 Well ID# MW-3 D 25.0 ft- 28.0 ft- SANDY CLAY
Sa.Well Location: 28.0 ft' 35.0 ft' FINE TAN SILTY SAND
SPEEDWAY- 8187 ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
bm•�®_7 '�-.:,i C/1"i4�G�
14477 US - 17 HAMPSTEAD 28443 ft. ft.
Physical Address,City,and Zip ft. ft. J U N 202_
PENDER 21.REMARKS .
County Parcel Identification No.(PIN) BENTONIfE SEAL-26.0-29.0 FED
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
340 21' 54.50" N 770 42' 49.35" N 05/10/22
6.Is(are)the well(s): 191'ermanent or ❑Temporary Signature ofCertified Well Contractor Date
By signing this form,I hereby certify that the ivell(s)was(were)constructed in accordance ivith
7.Is this a repair to an existing well: ❑Yes or MNo 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 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 Ovee in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 35.0 (ft*)
For multiple wells list all depths ifdifjerent(example-3@200'and 2Q100D Submit this GW-1 Within 30 days of well completion per the following:
10.Static water level below top of casing: 10.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+"
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 12.0/5.875 (in) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER/MUD ROTARY
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