GW1-2021-00335_Well Construction - GW1_20210127

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JACOB M ESSICK 14.WATER ZONES
Well Contrav s Name FR051 TO DESCRIPTION
ft. ft.
A - 4252 D. It.
NC Well Contractor Cenificaron Number 15.OUTER CASING n.r multi<ued we Its)OR LINER i/v liable
GEOLOGIC EXPLORATION, INC FROM To DIAMETER THICKNESS MATERIAL
n. n. n
C'oinpam'Name
16.INNER CASING OR TOBING eotbermvl dosed-too
2.N'ell Conslruclion Permit p: FROM l0 DIAMEER THICKNIS MATERIAL
1.,,,„nnr'/,hnnnn•Ireu eon.""oon"a"'p.e. UR e,,,,nn.Sun,rnr,nn...ercl 0.0 rL 26.0 ft. 2.0 SCH 40 PVC
3.Well Use(check well use): rl. ft. '
N-ater Supply Well: 17.SCREEN
Rest I TO DIAMETER SLOTSIZE THICKNESS AATERIAL
❑Agricultural ❑Municipal/Public n. nu ,
26.0 41.0 2.0 .010 SCH 40 PVC
❑Geothennal(Heming/Cooling Supply) ❑Residential Water Supply(single) fl ft in,
Olndustrial/Commercial ❑Residential Water Supply(shared) Ia.GROUT
❑Irrican(in ❑Wells> 100,000 GPD FRONI T(I SIATF.RL\L EMPLACENIENTMUROD&ANIOUV"
Non-Water Supply Well: 0.0 It. 20.0 It. PORTLAND eENTorvm SLURRY
MMonitoring []Recovery' ft. ft.
Injection Well:
[]Aquifer Recharge ❑Groundealer Remedialion
19.5:1NU/GRAVEL PACK ifapplicable)
❑AOWter SlOmgC and RPCOV'ell ❑Salinity Barrier FROM IO MATERIAL EMPLACfT1ENT METIfOD
❑Aquifer"test ❑Stormsvater Drainage 23.0 D' 41.0 ft 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subs"idence Control D- rt.
❑Geothernial(Closed Loop) ❑Tracer 20.DRILLING LOG ont.ch additional been if nertsoa
ClGeothermal(Healing/Coolmg Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION mlur,herdnew.soiooxk Leta.
ED D' 5.0 D' RED/BROWN SILTY CLAY
4.Date Well(s)Completed: 01/14/21 Well ID# IW 2 1 5.0 rL 20.0 rL TAN SILT
SA.Well location: 20.0 D' 41.0 rL BROWN SILT
CCI FLEET SUPPLY ft. rL
Facdo,Ow rcr`.anic Facility IDv litnppliauhlcl ft. It.
2744 WEST MOUNTAIN ROAD KERNERSVILLE 27284 ft. ft.-
Ph,oc.l Address.City.old Zip rt. ft.
FORSYTH 21.REMARKS
Comny Parcel Identification No.(PIN) BENTONITE SEAL- 20.0-23.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
tifuell field,one lat/long is su Rcient) 22.Certification:
360 06' 48.33" N 800 09' 43.32" W 10k 4"u'-d" 1/15/2021
6.Is(are)the w'ell(s): flPermament or OTemporan, Signature of'Cenlfie l Well Contractor Date
M.,gnurg,b:rfrom,llurch...r1o,',hn,,he yell(+9 vie prrry oomo-ormJ n,n..... neeumn
7.Is this a repair to an existing well: ❑Yes or 19No IM M V 02( Woo,15A A'( h 02t' 0200 Wrll l'on.dnmlion.xrnndonla and dsa o rupr
INh,,,.r orrpair,fill nu,kn,, n.oa //aurtgnttvinni,j rrnmim,and captain,hr namru a%,hr ol,h......nrdlmo lean prurided lu oo,yell oumue
y .k, dl k-=rceo, tle h...A ofo on,A,nn.
2J.Site diagram or additional well details:
8 For Geoprobe/DPT or Closed Loop Geothermal Wells havingg((Itc,sany rj (J n u may use the back ol'this page to provide additional scell construction into
construction,only I GW-1 is needed. Indicate TOTAL NUMBGk1pf Wills' (add'See Over'in Remarks Box).You may also attach additional pages ifnecessarr.
drilled_ 24.SUBi\IITTAL INSTRI1CTIONS
9.'1 otal well depth below land surface: 41.0 (ft.)
Fnr multiply�rellvluvnlldeoh,odof rnu(erm,ple-3C200'm02.u/00) Submit this GW-I within 30 days ofwell completion per the following:
Ill.Static water level below top of casing: 30.0 Ift) 24a. For All Wells: Original form to Division of Water Resources (DWR),
//inn.r le,r/r,nhovr aa.,,,g_n.e " Information Processing Unit, 1617 MSC.Raleigh,NC 27699-1617
11.Borehole diameter: 8.0 (i n.) 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 Water Suppivental h and Open-Loop Geothermal Return Wells:Cop) to the
u e auger,rofap�,cable.dircn push,eml county environmental health department of the county where installed
FOR WATER SUPPLI'WELLS ONLY: 24d. For Water Wells nrpducinE ayer I00.000 GPD:Copy to DWR,C'C'PCUA
Permit Program, 161 I MSC,Raleigh,NC 27699-161 I
13a.field(gpm) Method of test:
13b.Disinfection type: Amount:
Fonn GW-I Nonb Carolina Depannfeal of Environmental Qualify-Division of Winer Resources Re„sed 6A-2018