GW1-2021-00296_Well Construction - GW1_20210127

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
NC Well Contractor Certification Number 15.OUTER CASING for mold<med wells OIL
ifa liable
GEOLOGIC EXPLORATION FROM TO DIAMLTER THICKNESS MATEx1AL
rt. D.
Company Name n
16.INNER CASING OR TUBING other at closed-too
2.Well Construction Permit#: FROM TO DIAsaug, THICKNESS MATERIAL
[.i.n all applloable troll aon.vr0000n pe,,o o.e. [/1(i C'omrm,.Sloe. Varicose,eu.) 0.0 It. 5.0 f. 2.0 in. SCH 40 PVC
3.Well Use(check well use): ft. n, in.
\Pater Supply Well: 17.SCREEN
FROM To I DIAMETER I SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5.0 n. 30.0 D' 2.0 in- .010 SCH 40 PVC
❑Geothermal(Heating/Cooking Supply) ❑Residential Water SupPly(single) R D
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl atlon ❑Wells'> 100,000 GPD FROM TO MATERIAL EMPLACEMENT MFIIOD&AMOUNT
Non-Water Supply Well: 0.0 R, 2.0 ft PoanaNO etNrONiTe SLURRY
OMonforing ❑Recovery ft. n.
Injection Well: ft D
❑Aquifer Recharge OGroundwater Remediation
19.SANU/GRAVEL PACK ii arnaluc.ble
❑AgUlf¢r$IOmgC and RCCDVCry ❑$almlry 83Rler FROM I TO MATERIAL EMPIACfaIfNTbrf:'r'110U
❑Aquifer test ❑Stormwater Drainage 4.0 fL 30.0 fL 20-40 FINESILICASAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ElTracer 20.DRILLING LOG attach additional sheep if necessa
❑Geothermal(Heating/Cooling Return) LlOther(exlain under 421 Remarks) FROM TO DESCRI"IOrveolaq hvrdnev,miUmek mc,eu.
0.0 ft- 15.0 ft' TAN SAND
4.Date W'elbs)Completed: 01/11/21 Well ID# MW-1 15.0 f- 30.0 ff GRAY/BLACK SAND
Sa.Well Location:
t. n.
WRIGHT CHEMICAL f. ft.
Fachniowner Name Facility[DO jifa,Plicable) ft. n,
333 NEILS EDDY ROAD RIEGELWOOD 28456 ft, f°
Physical Address,City,and Zip ft. R-
COLUMBUS 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL- 2.0-4.0 FT
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field,one lat/long is sufficient) 22.Certification:
340 19' 36.64" N, 780 12' 04.70" W "�'� 1/15/2021
6. Is(are)the well(s): MPermanent or OTemporary Signature ofCcomed Well Contractor Date
N)'xiening rlus b.rrn,I hereby can/p that the well(,,)uwr'/vale/rnn,vurred o.......done vah
7.Is this a repair to an existing well: ❑Yes or [-]No 1S9 N( 4( 02r .0100 nr l34 MAR 02('.0200 Well('......coon.Smndardc cod tho a eopr
If due h o repair,/Ill on,knoun yell cnnasuc(ion nift a f o,and eipr un the nacre f the• ny on,,card La.r h,n prodded to oh,yell owner.
re/wv tinder-21 remark,secnnrr or on the baak n(tlhr/orm. n 1
,1 'CCU e 1 23.Site diagram or additional well details:
/3'ame You may use the back of this page to provide additional well construction info
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells Bark the
construction,only I GW-I is needed. Indicate TOTAL NUMBER ofwells (add'See Ovef in Remarks Box).You may also attach additional pages ifnecessars
drilled'. 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below'land surface: 30.0 (ft.)
I..r muntple ne11e,h,1 of deplh, f h11J rem lexnntple-3©200 co,120I00) Submit this GW-1 within 30 days of well completion per the fallowing:
10.Static water level below tap ofcasing: 15.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
o rarer hrc1 i.,obore envug,are 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 WaterSuppiv and O en-Loo Geothermal Return\Veils Copy to the
(ie auger,rotary-cable,direct push,ate.) county environmental health department of t e 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 attest:
13b.Disinfection type: Amount:
For GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018