GW1-2021-00297_Well Construction - GW1_20210127

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JACOB MESSICK 14.WATER ZONES
Nell Commctor Name FROM Ft. TO DESCRIPTION
A - 4252 a
n. n.
NC Well Contractor Certification Number 15.OUTER CASING formula-cued wells OILINER ifa liable
GEOLOGIC EXPLORATION iR0]I TO MAII LTER THICKNESS NIATEHIAL
n. D.
'n.Company Name
16.INNER CASING OR TUBING eothermal closed-too
2.W'ell Construction Permit#: FRO.N TO DIAMETER THICKNESS MATERIAL
l.ur all npplanhle cell rrn......rno.r prrnr;nr I e_lfl(' r..... Sinn•.n.'a,"�.errJ 0.0 n, 5.0 D, 2.0 In' SCH 40 PVC
3.Well Use(check well use): ft. ft. t
n.
Water Supply"'ell: 17.SCREEN
FROM I TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5.0 h' 30.0 f- 2.0 in. .010 SCH 40 PVC
❑Geothermal(Healing/Cooling Supply) ❑Residential Water Supply(single) !t ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrlation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPIA('EMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 fL 2.0 It' PoaruNo aENTONF[ SLURRY
tilMoniloring ❑Recovery D. ft.
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remedialion
19.SAND/GRAVEL PACK Its IkWe
Agui ter Storage and Reco,er% ❑Salinity Barrier FROM TO MATERIAL I ESIPLACEh1ENT METHOD
❑Aquifer Test ❑Stonmvater Drainage 4.0 fL 30.0 fL 20-40 FINESILICASAND
❑ENperimental Technology ❑Subsidence Control D. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG anaeh additional sheeb ifeumeso
❑Geothermal(Heating/Cooling Return) ❑Olher(explain under 921 Remarks) FROM To DEscRIPrION .Dior,n.rd�.::,.niDra<t ,<..m.
0.0 ft- 15.0 f'• TAN SAND
4.Date Well(s)Completed: 01/12/21 Well ID# MW-3 15.0 fL 30.0 ft- GRAY/BLACK SAND
Sa.Well Location: ft. ft.
WRIGHT CHEMICAL " ft.
Facilirv'Owncr,None Facility ID-tifapplicable) ft. ft.
333 NEILS EDDY ROAD RIEGELWOOD 28456 f. rN
Physical Address,Cay.and Zip ft. ft.
COLUMBUS 21.REMARKS
County Parcel Identification No,(PIN) BENTONUE SEAL- 2.0-4.0 FT
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
I ifwell field.one let i Inn,is saRciem) 22.Certification: �l
340 19' 36.64" N 780 12' 04.70" W 1/15/2021
6.]store)the well(s): RPermanent or OTemporary Signature ofCerified Well Contractor Dam
to vgning rGu lrrnrr,llrurehv cer,JF dray rGe u,lgs/ua.r(ogre/mnvnmred m aeaurdance u al,
7. Is this a repair to a0 existing well: ❑Yes or 15No lA.h'('L('117('.0100 or 19.4 A'('d( 07(' 0200 n'ell('nr.c(ruebnrr S'rrudmd,nnJ four n rapt
IJ ions ,o repur,fill our km.....r..ell nm.I...I a a.jo,au uun mr 1 espl un the norure of he of du,record Ims he,,,prvna led,,roe urll ounce
rcryrr unJrr 21 fro rksse,uun nrunthe barkglrh,jornr
23.Site diagram or additional well details:
8.For Geoprobe/DI'f or Closed-Loop Geothermal Wells having the same You mac use the back of this page to provide additional %cell construction mPo
construction.only 1 GW-I is needed Indicate TOTAL NUMBER ofwells Ladd'See O%ee in Remarks Box) You ma}also attach additional paces it neccssarc
drilled Z4.SUBMITFAL INSTRUCTIONS
0 7
9.Total well depth below land surface: 30.
IT-Submit this GW4 within 30 days of well completion per the following:
Par muGgde actin live n/I depros J dr(/dnvn/c:xnnrp/n-3 n?rY)'nod l tdl ')
15.0 24a. For All Wells: Original form to Division of Water Resources' (DWR),
10.Static water level below top of casing: (fL) Information Processing Unit. 1617 MSC,Raleigh,NC 27699-1617
l/timer lnal i,a nhoru ev.rnrg.use"-
11.Borehole diameter: 8.0 (in.) 24b. For Injection We1Is: Cop)'to DWR,Underground Injection Control (IUC)
Program. 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER
24c.For Water ntal and Open-Loop Geothermal Return Wells:Cop.•to the
fie auger,roraq,cable,threat push,etc county environmental health department of county%there installed
FOR WATER SUPPLI WELLS ONL\': 24d. For Water Wells producing over 100,000 GPD: Copy to DW'R.C'CPCUA
Permit Program, 1611 MSC.Raleigh,NC 2 7699-16 1 1
13a.field(gpm) Method of lest:
13b.Disinfection type: Amount:
Form G W-I North Carolina Deparnneru of Environmcnml Quality-Division of Water Resources Revised 6-6-NJ IE