GW1--03042_Well Construction - GW1_20230310

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JACOB MESSICK 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
A - 4252 ft. ft.
ft. tr.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable)
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name '
16.INNER CASING OR TUBING(geothermal closed-loon)
2.Well Construction Permit#• FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable bell construction perntils(i.e.U/C,County,Slate,Variance,etc) 0.0 if 42.0 ff 1.0 '"' SCH 40 PVC
3.Well Use(check well use): 0.0 ft 5.0 ft• 1.0 '"' SCH 40 PVC
Water Supply Well: 17.SCREEN
FROM TO DIAMETER I SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 42.0 ff 47.0 tt. 1.0 in. 010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 5.0 tt' 20.0 ft' 1.0 in. .010 SCH 40 PVC
❑Industrial/Commercial ❑Residential Water Supply(shared) I&GROUT
❑irrl ation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 2.0 ft' PORTLAND BENTONITE SLURRY
OMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 40.0 fl• 47.0 ft. 20-40 T FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control 4.0 ft. 22.0 ft. 20-40 1 FINE SILICA SAND
❑Geothermmal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness,soi0rock type rain size,etc.
0.0 ft. 5.0 ft- BROWN SILTY CLAY
4.Date WeII(S)Completed: 02/O7/23 Well ID# TMW-2 5.0 ft' 47.0 ft- BROWN/TAN,SANDY SILT1`;,;
Sa.Well Location: ft. ft.
BENFIELD CHEMICALS ft. ft. n A 11 �C12
Facility/Owner Name Facility ID#(if applicable) ft. fr.
6108 OLD CLYDE ROAD CANTON 28716
Physical Address,City,and Zip ft. ft. -
HAYWOOD 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-22.0-40.0 FEET&2.0-4.0 FEET
Sb.Latitude and longitude in degreeslminutes/seconds or decimal degrees:
***NESTED WELLS***
(if well field,one lit/long is sufficient) 22.Certification:
350 32' 12.39" N 820 52' 07.51" W 01 02/23/23
6.Is(are)the well(s): ❑Permanent or (ETemporary Signature of Certified Well Contractor Date
By signing this form,1 hereby terrify that the u,ell(s)was(were)consirucled in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
/f this is a repair,fill our known well construction it formation and explain the nature oJ'1he of this record has been provided to the well owner.
repair under i: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 I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Ove1'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 47.0/20.0 (ft.)
For nwhiple wells list all depths ifdi/ferent(example-3 rr 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: 10.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
1Jlraler level is above easing,use"+^ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
8.0 24b. For Injection Wells: Copy to DWR,Underground Injection Control (IUC)
11.Borehole diameter: (in.) Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER
24c.For Water Supplv 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
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018