AS-1789_20326_CA_WR_20230227_ASandRW

WithersRavenel
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APPENDIX A 

REMEDIAL WELL CONSTRUCTION RECORDS 

WELL CONSTRUCTION RECORD (GW-1)For Internal Use Only:
Form GW-1 North Carolina Department of Environmental Quality - Division of Water Resources Revised 6-6-2018
1. Well Contractor Information:
Well Contractor Name
NC Well Contractor Certification Number
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
ƑAgricultural ƑMunicipal/Public
ƑGeothermal (Heating/Cooling Supply)ƑResidential Water Supply (single)
ƑIndustrial/Commercial ƑResidential Water Supply (shared)
ƑIrrigation ƑWells > 100,000 GPD
Non-Water Supply Well:
ƑMonitoring ƑRecovery
Injection Well:
ƑAquifer Recharge ƑGroundwater Remediation
ƑAquifer Storage and Recovery ƑSalinity Barrier
ƑAquifer Test ƑStormwater Drainage
ƑExperimental Technology ƑSubsidence Control
ƑGeothermal (Closed Loop)ƑTracer
ƑGeothermal (Heating/Cooling Return) ƑOther (explain under #21 Remarks)
4. Date Well(s) Completed: Well ID#
5a. Well Location:
Facility/Owner Name Facility ID# (if applicable)
Physical Address, City, and Zip
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
N W
6. Is(are) the well(s): ƑPermanent or ƑTemporary
7. Is this a repair to an existing well: ƑYes or ƑNo
If this is a repair, fill out known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
8. For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface: (ft.)
For multiple wells list all depths if different (example- 3@200’ and 2@100ƍ)
10. Static water level below top of casing: (ft.)
If water level is above casing, use “+”
11. Borehole diameter: (in.)
12. Well construction method:
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
14. WATER ZONES
FROM TO DESCRIPTION
ft.ft.
ft.ft.
15. OUTER CASING (for multi-cased wells) OR LINER (if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
ft.ft.in.
16. INNER CASING OR TUBING (geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
ft.ft.in.
ft.ft.in.
17. SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft.ft.in.
ft.ft.in.
18. GROUT
FROM TO MATERIAL EMPLACEMENT METHOD & AMOUNT
ft.ft.
ft.ft.
ft.ft.
19. SAND/GRAVEL PACK (if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
ft.ft.
ft.ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM TO DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
ft.ft.
ft.ft.
ft.ft.
ft.ft.
ft.ft.
ft.ft.
ft.ft.
21. REMARKS
22. Certification:
Signature of Certified Well Contractor Date
By signing this form, I hereby certify that the well(s) was (were) constructed in accordance with
15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a copy
of this record has been provided to the well owner.
Site diagram or additional well details:
You may use the back of this page to provide additional ZHOOFRQVWUXFWLRQLQIRDGG
6HH2YHU
LQ5HPDUNV%R[<RXPD\DOVRDWWDFKDGGLWLRQDOSDJHVLIQHFHVVDU\
SUBMITTAL INSTRUCTIONS
Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells:Original form to Division of Water Resources (DWR),
Information Processing Unit, 1617 MSC, Raleigh, NC 27699-1617
24b. For Injection Wells:Copy to DWR, Underground Injection Control (IUC)
Program, 1636 MSC, Raleigh, NC 27699-1636
24c. For Water Supply and Open-Loop Geothermal Return Wells: Copy to the county environmental health department of the county where installed
24d. For Water Wells producing over 100,000 GPD: Copy to DWR, CCPCUAPermit Program, 1611 MSC, Raleigh, NC 27699-1611
JACOB MESSICK
A - 4252
GEOLOGIC EXPLORATION

0.0 35.0 SCH 40
35.0 40.0 .010
●
0.0 PORTLAND BENTONITE
33.0 20-40
0.0 BROWN/TAN SILTY CLAY 02/27/23 AS-1 15.0 TAN SILT
30.0 TAN SILTY SAND
FOOTHILLS SERVICE CENTER
312 EAST UNION STREET MORGANTON 28655
BURKE BENTONITE SEAL ~ 30.0 - 33.0 FEET
35° 44' 52.16" 81° 41' 07.47"03/24/23
●
40.0
33.0
8.0
AUGER
PVC
SCH 40 PVC
2.0

2.0
30.0
40.0
15.0
30.0
40.0
FINE SILICA SAND
SLURRY
WELL CONSTRUCTION RECORD (GW-1)For Internal Use Only:
Form GW-1 North Carolina Department of Environmental Quality - Division of Water Resources Revised 6-6-2018
1. Well Contractor Information:
Well Contractor Name
NC Well Contractor Certification Number
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
ƑAgricultural ƑMunicipal/Public
ƑGeothermal (Heating/Cooling Supply)ƑResidential Water Supply (single)
ƑIndustrial/Commercial ƑResidential Water Supply (shared)
ƑIrrigation ƑWells > 100,000 GPD
Non-Water Supply Well:
ƑMonitoring ƑRecovery
Injection Well:
ƑAquifer Recharge ƑGroundwater Remediation
ƑAquifer Storage and Recovery ƑSalinity Barrier
ƑAquifer Test ƑStormwater Drainage
ƑExperimental Technology ƑSubsidence Control
ƑGeothermal (Closed Loop)ƑTracer
ƑGeothermal (Heating/Cooling Return) ƑOther (explain under #21 Remarks)
4. Date Well(s) Completed: Well ID#
5a. Well Location:
Facility/Owner Name Facility ID# (if applicable)
Physical Address, City, and Zip
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
N W
6. Is(are) the well(s): ƑPermanent or ƑTemporary
7. Is this a repair to an existing well: ƑYes or ƑNo
If this is a repair, fill out known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
8. For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface: (ft.)
For multiple wells list all depths if different (example- 3@200’ and 2@100ƍ)
10. Static water level below top of casing: (ft.)
If water level is above casing, use “+”
11. Borehole diameter: (in.)
12. Well construction method:
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
14. WATER ZONES
FROM TO DESCRIPTION
ft.ft.
ft.ft.
15. OUTER CASING (for multi-cased wells) OR LINER (if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
ft.ft.in.
16. INNER CASING OR TUBING (geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
ft.ft.in.
ft.ft.in.
17. SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft.ft.in.
ft.ft.in.
18. GROUT
FROM TO MATERIAL EMPLACEMENT METHOD & AMOUNT
ft.ft.
ft.ft.
ft.ft.
19. SAND/GRAVEL PACK (if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
ft.ft.
ft.ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM TO DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
ft.ft.
ft.ft.
ft.ft.
ft.ft.
ft.ft.
ft.ft.
ft.ft.
21. REMARKS
22. Certification:
Signature of Certified Well Contractor Date
By signing this form, I hereby certify that the well(s) was (were) constructed in accordance with
15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a copy
of this record has been provided to the well owner.
Site diagram or additional well details:
You may use the back of this page to provide additional ZHOOFRQVWUXFWLRQLQIRDGG
6HH2YHU
LQ5HPDUNV%R[<RXPD\DOVRDWWDFKDGGLWLRQDOSDJHVLIQHFHVVDU\
SUBMITTAL INSTRUCTIONS
Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells:Original form to Division of Water Resources (DWR),
Information Processing Unit, 1617 MSC, Raleigh, NC 27699-1617
24b. For Injection Wells:Copy to DWR, Underground Injection Control (IUC)
Program, 1636 MSC, Raleigh, NC 27699-1636
24c. For Water Supply and Open-Loop Geothermal Return Wells: Copy to the county environmental health department of the county where installed
24d. For Water Wells producing over 100,000 GPD: Copy to DWR, CCPCUAPermit Program, 1611 MSC, Raleigh, NC 27699-1611
JACOB MESSICK
A - 4252
GEOLOGIC EXPLORATION

0.0 35.0 SCH 40
35.0 40.0 .010
●
0.0 PORTLAND BENTONITE
33.0 20-40
0.0 BROWN/TAN SILTY CLAY 02/27/23 AS-2 15.0 TAN SILT
30.0 TAN SILTY SAND
FOOTHILLS SERVICE CENTER
312 EAST UNION STREET MORGANTON 28655
BURKE BENTONITE SEAL ~ 30.0 - 33.0 FEET
35° 44' 52.16" 81° 41' 07.47"03/24/23
●
40.0
33.0
8.0
AUGER
PVC
SCH 40 PVC
2.0

2.0
30.0
40.0
15.0
30.0
40.0
FINE SILICA SAND
SLURRY
WELL CONSTRUCTION RECORD (GW-1)For Internal Use Only:
Form GW-1 North Carolina Department of Environmental Quality - Division of Water Resources Revised 6-6-2018
1. Well Contractor Information:
Well Contractor Name
NC Well Contractor Certification Number
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
ƑAgricultural ƑMunicipal/Public
ƑGeothermal (Heating/Cooling Supply)ƑResidential Water Supply (single)
ƑIndustrial/Commercial ƑResidential Water Supply (shared)
ƑIrrigation ƑWells > 100,000 GPD
Non-Water Supply Well:
ƑMonitoring ƑRecovery
Injection Well:
ƑAquifer Recharge ƑGroundwater Remediation
ƑAquifer Storage and Recovery ƑSalinity Barrier
ƑAquifer Test ƑStormwater Drainage
ƑExperimental Technology ƑSubsidence Control
ƑGeothermal (Closed Loop)ƑTracer
ƑGeothermal (Heating/Cooling Return) ƑOther (explain under #21 Remarks)
4. Date Well(s) Completed: Well ID#
5a. Well Location:
Facility/Owner Name Facility ID# (if applicable)
Physical Address, City, and Zip
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
N W
6. Is(are) the well(s): ƑPermanent or ƑTemporary
7. Is this a repair to an existing well: ƑYes or ƑNo
If this is a repair, fill out known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
8. For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface: (ft.)
For multiple wells list all depths if different (example- 3@200’ and 2@100ƍ)
10. Static water level below top of casing: (ft.)
If water level is above casing, use “+”
11. Borehole diameter: (in.)
12. Well construction method:
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
14. WATER ZONES
FROM TO DESCRIPTION
ft.ft.
ft.ft.
15. OUTER CASING (for multi-cased wells) OR LINER (if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
ft.ft.in.
16. INNER CASING OR TUBING (geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
ft.ft.in.
ft.ft.in.
17. SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft.ft.in.
ft.ft.in.
18. GROUT
FROM TO MATERIAL EMPLACEMENT METHOD & AMOUNT
ft.ft.
ft.ft.
ft.ft.
19. SAND/GRAVEL PACK (if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
ft.ft.
ft.ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM TO DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
ft.ft.
ft.ft.
ft.ft.
ft.ft.
ft.ft.
ft.ft.
ft.ft.
21. REMARKS
22. Certification:
Signature of Certified Well Contractor Date
By signing this form, I hereby certify that the well(s) was (were) constructed in accordance with
15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a copy
of this record has been provided to the well owner.
Site diagram or additional well details:
You may use the back of this page to provide additional ZHOOFRQVWUXFWLRQLQIRDGG
6HH2YHU
LQ5HPDUNV%R[<RXPD\DOVRDWWDFKDGGLWLRQDOSDJHVLIQHFHVVDU\
SUBMITTAL INSTRUCTIONS
Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells:Original form to Division of Water Resources (DWR),
Information Processing Unit, 1617 MSC, Raleigh, NC 27699-1617
24b. For Injection Wells:Copy to DWR, Underground Injection Control (IUC)
Program, 1636 MSC, Raleigh, NC 27699-1636
24c. For Water Supply and Open-Loop Geothermal Return Wells: Copy to the county environmental health department of the county where installed
24d. For Water Wells producing over 100,000 GPD: Copy to DWR, CCPCUAPermit Program, 1611 MSC, Raleigh, NC 27699-1611
JACOB MESSICK
A - 4252
GEOLOGIC EXPLORATION

0.0 35.0 SCH 40
35.0 40.0 .010
●
0.0 PORTLAND BENTONITE
33.0 20-40
0.0 BROWN/TAN SILTY CLAY 02/28/23 AS-3 15.0 TAN SILT
30.0 TAN SILTY SAND
FOOTHILLS SERVICE CENTER
312 EAST UNION STREET MORGANTON 28655
BURKE BENTONITE SEAL ~ 30.0 - 33.0 FEET
35° 44' 52.16" 81° 41' 07.47"03/24/23
●
40.0
33.0
8.0
AUGER
PVC
SCH 40 PVC
2.0

2.0
30.0
40.0
15.0
30.0
40.0
FINE SILICA SAND
SLURRY
WELL CONSTRUCTION RECORD (GW-1)For Internal Use Only:
Form GW-1 North Carolina Department of Environmental Quality - Division of Water Resources Revised 6-6-2018
1. Well Contractor Information:
Well Contractor Name
NC Well Contractor Certification Number
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
ƑAgricultural ƑMunicipal/Public
ƑGeothermal (Heating/Cooling Supply)ƑResidential Water Supply (single)
ƑIndustrial/Commercial ƑResidential Water Supply (shared)
ƑIrrigation ƑWells > 100,000 GPD
Non-Water Supply Well:
ƑMonitoring ƑRecovery
Injection Well:
ƑAquifer Recharge ƑGroundwater Remediation
ƑAquifer Storage and Recovery ƑSalinity Barrier
ƑAquifer Test ƑStormwater Drainage
ƑExperimental Technology ƑSubsidence Control
ƑGeothermal (Closed Loop)ƑTracer
ƑGeothermal (Heating/Cooling Return) ƑOther (explain under #21 Remarks)
4. Date Well(s) Completed: Well ID#
5a. Well Location:
Facility/Owner Name Facility ID# (if applicable)
Physical Address, City, and Zip
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
N W
6. Is(are) the well(s): ƑPermanent or ƑTemporary
7. Is this a repair to an existing well: ƑYes or ƑNo
If this is a repair, fill out known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
8. For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface: (ft.)
For multiple wells list all depths if different (example- 3@200’ and 2@100ƍ)
10. Static water level below top of casing: (ft.)
If water level is above casing, use “+”
11. Borehole diameter: (in.)
12. Well construction method:
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
14. WATER ZONES
FROM TO DESCRIPTION
ft.ft.
ft.ft.
15. OUTER CASING (for multi-cased wells) OR LINER (if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
ft.ft.in.
16. INNER CASING OR TUBING (geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
ft.ft.in.
ft.ft.in.
17. SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft.ft.in.
ft.ft.in.
18. GROUT
FROM TO MATERIAL EMPLACEMENT METHOD & AMOUNT
ft.ft.
ft.ft.
ft.ft.
19. SAND/GRAVEL PACK (if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
ft.ft.
ft.ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM TO DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
ft.ft.
ft.ft.
ft.ft.
ft.ft.
ft.ft.
ft.ft.
ft.ft.
21. REMARKS
22. Certification:
Signature of Certified Well Contractor Date
By signing this form, I hereby certify that the well(s) was (were) constructed in accordance with
15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a copy
of this record has been provided to the well owner.
Site diagram or additional well details:
You may use the back of this page to provide additional ZHOOFRQVWUXFWLRQLQIRDGG
6HH2YHU
LQ5HPDUNV%R[<RXPD\DOVRDWWDFKDGGLWLRQDOSDJHVLIQHFHVVDU\
SUBMITTAL INSTRUCTIONS
Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells:Original form to Division of Water Resources (DWR),
Information Processing Unit, 1617 MSC, Raleigh, NC 27699-1617
24b. For Injection Wells:Copy to DWR, Underground Injection Control (IUC)
Program, 1636 MSC, Raleigh, NC 27699-1636
24c. For Water Supply and Open-Loop Geothermal Return Wells: Copy to the county environmental health department of the county where installed
24d. For Water Wells producing over 100,000 GPD: Copy to DWR, CCPCUAPermit Program, 1611 MSC, Raleigh, NC 27699-1611
JACOB MESSICK
A - 4252
GEOLOGIC EXPLORATION

0.0 25.0 SCH 40
25.0 40.0 .010
●
0.0 PORTLAND BENTONITE
23.0 20-40
0.0 BROWN/TAN SILTY CLAY 02/28/23 RW-1 15.0 TAN SILT
30.0 TAN SILTY SAND
FOOTHILLS SERVICE CENTER
312 EAST UNION STREET MORGANTON 28655
BURKE BENTONITE SEAL ~ 20.0 - 23.0 FEET
35° 44' 52.16" 81° 41' 07.47"03/24/23
●
40.0
33.0
8.0
AUGER
PVC
SCH 40 PVC
4.0

4.0
20.0
40.0
15.0
30.0
40.0
FINE SILICA SAND
SLURRY