GW1-2021-00343_Well Construction - GW1_20210127

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.Well Contractor Information:
JACOB MESSICK 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
fl. ft.
A - 4252
n. n.
NC Well Contractor Certification Number 15.OUTER CASING for multi<ued welh OR LINER if applicable)
GEOLOGIC EXPLORATION FROM TO D0.m-MR THICKNESS MATERIAL
ft. IL in.
Company Name
16.INNER CASING OR TUBING eoftermatclmee-too
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
I.m au appheanlehen cahsrrnemm pe,amsn.c. tfl(.Canter.Stem, varlanre,ere./ 0.0 f- 7.0 D' 2.0 in- SCH40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM I TO DMNILTER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 70 ft' 17.0 f' 2.0 '"' .010 SCH 40 PVC
❑Geothermal(Healing/Cooling Supply) ❑Residential Water Supply(single) ft ft. I
n.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
Ofinization ❑Wclls> 100.000GPD FROM 1 TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 3.0 ft. Poarmuo sruromrP SLURRY
1EMonitoring ❑Recovery ft. ft.
Injection Well: 0 fl
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAV amidiable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM 10 MATERIAL EMPLACF.MEM'METIIOD
❑Aquifer Test OSlormwaler Drainage 5.0 fL 17.0 fE 20-40 F[NE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. I D.
❑Geothermal(Closed Loop) OTmcer 20.DRILLING LOG hariaeh additional sheets if necessary)
❑Geothermal(Healing/Cooling Return) ❑Olher(explain under 421 Remarks) FROM Ta DESCRIPTION luilar,hardneve,.wiVealk er,etc.
&0 h. 10.0 ft. BROWN/TAN SILTY CLAY
4.Date Wells)Completed: 01/15/21 Nell ID# MW-41 10.0 fL 17.0 D- TAN SILTY SAND
ft.
is.Well Location: ft.
IREDELL COUNTY LANDFILL rt. ft.
F.da, Name Facllip IDP(dappricable) ft. ft.
354 TWIN OAKS ROAD STATESVILLE 28625 ft. ft.
Physical Address,City,and Zip H. D-
IREDELL 21.REMARKS
County Parcel lrknuficw....No.(PIN) BENTONITE SEAL- 3.0-5.0 FT
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
nfoell field,one I.Clong is suflk.crin 22.Certification:
350 46' 15.64" N 800 48' 45.17" W '°�a�' 1/15/2021
6.ls(are)the well(s): MPermanent or OTemporan, Signature ofCcrufird Well Contractor Dam
Hi ,,rurc,m,f rm,I h,,b,,erhlF dear,the vell(s/vuc(irere)crrnerruclrAm anvrdaner ui1h
7.Is this a repair to an existing well: ❑Yes or MNo 15.E NCu 02C 0I00 ar 15.i NCdC 02( 11200 Well Comrru000rr 9wo0anh arrd 11 1 u dupe
Il de,is a repair fill ow khan-..uc11 rnnvrucriou Infinnmrlml and erplaur Ore s."we o/the of 11..mooed h,,been prurlded ro Tire ,ell owner.
repair under 21 remmis archon or un the hark fdris%arm_
23.Site diagram or additional well details:
8.For Geoprobe/DPf or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction into
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessar.'
drilled- 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Leh') Submit this GW-E within 30 days of well completion r the following:
Par nruluple yells her all depth,fdq/e,,,1(penrnpi, 3(gl2lHl'm¢12. �Il 5 P R
10.Static water level below top ofcasing: 3.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR).
I/ rarer hreh,anon ea.�nR.hce Intonnation Processing Unit, 1617 MSC,Raleigh,INC 27699-1617
11.Borehole diameter: 8.0 (in.) 24b. For Infection Wells: Copy to DWR, Underground Injection Control (IUC
Program, 1636 MSC,Raleigh,NC 27699-1636
12.W'ell construction method: AUGER
lac For Water en Supply and O n-Lao Geothermal Return Wells:Copy to the
p e.auger,rotary,cable.direct push.etc.) county environmental health department o the count,'where installed
FOR WATER SUPPLY WELLS ONLI': 24d. For Water Wells producing over 100,000 GPD: Copy to DWR CCPCUA
13a.Yield(gpm) Method of test: Permit Program, 1611 MSC,Raleigh,NC 27699-1 61 1
Ellis Disinfection type: Amount:
Fonn GW-1 North Carolina Department of Envimnme cal Quality-Division of Water Resources Re.ised 6L-2018