GW1-2021-00336_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 R. R.
R. 1 D.
NC Well Contractor Certification Number 15.OUTER CASING for mold-cased welt ORLINER ifs livable
GEOLOGIC EXPLORATION, INC FROM TO DIAMETER THICKNESS MATERIAL
a. ft.
Company Name n.
16.INNER CASING OR TURING eothermalalosed-too
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
Lrvallapph,onle me//eonrrn¢rlarr pernaim', 1/1C.Omme.Slws, Vorm", em.l 00 0. 26.0 f. 2.0 ' SCH40 PVC
3.Well Use(check well use): ft. D. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 26.0 ft' 41.0 fit- 2.0 In' .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fit fit in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑lrri ahon ❑Wells> 100,000 GPD FROM 1 10 MATERIAL EMPL%CEMENTMETHOD&AMOUNT
Non-Water Supply Well: O.O ft. 20.0 fit' PORnAND BENTONnl SLURRY
tr Monitoring ❑Recovery
Injection Well:
fit. fit.
❑Aquiter Recharge ❑Groundtmter Remediation
19.SAND/GRAVEL PACK ifs livable
❑Aquifer Storage and Recovery ❑Salinity Barrier I MATERIAL EMPIACF,MENT ME ZOO
❑Aquiter Test ❑Stormwater Drainage 23.0 IN 41.0 fit- 20-40 FINESWCASAND
❑Experimental Technology ❑Subsidence Control ft. It.
❑Geolhennal(Closed Loop) ❑Tracer 20.DRILLING LOG atmchaddidonalsheebifnecesu
OGeothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) FROM To DESCRIPTION color,hardness,outlook Ora,soon sio,etc.
&0 f. 5.0 ft- RED/BROWN SILTY CLAY
4.Date Well(s)Completed: 01/14/21 Well ID# IW-2-2 SD fit• 20.0 fit- TAN SILT
5a.Well Location: 20.0 fit' 41.0 fit' BROWN SILT
CCI FLEET SUPPLY ft. ft.
Fncitiry;Owms home Facility lDa(ifapplieatir) ft. ft. _
2744 WEST MOUNTAIN ROAD KERNERSVILLE 27284 ft. ft
Physical Address,City,and Zip ft. ft.
FORSYTH 2L REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-20.0-23.0 FEET
Sta.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field,one Iat/long is sufficient) 22.Certification:
360 06' 48.33" N 800 09' 43.32" W Gsta-,dry 1/15/2021
6.[share)the wdl(s): OPermanent or OTemporary Signature ofCenified Well Contractor Date
8..egnuag 1;...Jbrrn,l h...hv c,ruiv rho,Jae cello)ma.r/were/evaransnd,,aeeorz6uue o ah
7 Is this a repair to an existing well ❑V es or [5No rnI '4L, U( /( o ('.oleo or li I yr -H 02! 11200 Wel/(o,oruour a bmedordr mul rear a rapt
bIl lair Jul bar kuman a ell .i ar f la r andeVA.....1,�nJttVrr rt"'oe ��'%1, e, ml las been prm idedro the cell auner
rclminnrdrr li2l reumkc.ucum rob dat be,kn)'rha,(rrnt N11
23.Site diagram or additional well details:
8.For Ceoprobe/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-I is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box)You may also attach addmonal pages ifneeessary
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 41.0 (ft.)
For unth,le well,or,all depth,l dp real/ecmuple-3@200'and 2nl00') Submit this G W-I within 30 days of well completion per the following:
10.Static water level below top creasing: 30.0 (fit) 24a. For All Wells: Original form to Division of Water Resources (DWR),
hrel is chore m.vrng,use
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
I)uanr ..-..
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 Water Supply and Open-Loop Geothermal Return Wells:Copy to the
ti c.auger,rotary,cable,direct push,etc.) county environmental health department ot`the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d. For Water Wells producing mar C100,000 GPD: Copy to DWR,CCPCUA
Permit Program, 1611 MSC.Roleigh,N 2 7699-161 1
13a.field(gpm) Method of test:
13b.Disinfection type: Amount:
Fonn G W-I North Carolina Department of Environmental Quality-Division or Water Resources Revised 6-6-2018