GW1-2021-00360_Well Construction - GW1_20210127

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: E
JACOB MESSICK _14.WATER ZONES ` e
Well Contractor Name FROM TO DESCRIPTION
A - 4252 ft. ft.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. fr. in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) 0•0 ft. 9.0 ft- 2.0 in. SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5.0 ft• 20.0 ft' 2.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fr ft in
❑Industrial/Commercial ❑Residential Water Supply(shared) '18•GROUT
❑IRA atlon ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0•0 ft^ 2.0 ft- PORTLAND BENTONITE SLURRY
OMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 3.0 ft- 20.0 ft' 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) FROM TO DESCRIPTION color,hardness,soil/mck type,grain sin,etc.
0.0 ft• 11.0 fL BROWN/TAN SILTY CLAY
4.Date Well(s)Completed: 01/06/21 Well ID# MW-1 11.0 ft• 200 ff TAN SANDY CLAY
Sa.Well Location:
ft. ft.
SPEEDWAY - 8276 ft. ft.
'Facility/Owner Name Facility ID#(ifaplrlicable) ft. ft.
2131 FOREST HILLS ROAD WEST WILSON 27893 ft. ft.
Physical Address,City,and Zip ft. ft•
WILSO N 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-2.0-3.0 FT
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one hit/long is sufficient) 22.Certification:
350 43' 49.34" N 770 57' 09.06" W IwO6 "0.'" 1/15/2021
6.Is(are)the well(s): [EPermanent or ❑Temporary Signature of Certified Well Contractor 7Date
^ By signing this form,l hereby certify that the well(s)iras(liver¢)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo-,°'' 15A NCAC 01C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a copy
lfthis is a repair,fill out known ivell construction information and expla'irrthe nature of the ofdtis record has been provided to due well aLrner.
repair under#21 remarks section or on the back of this form.
TOZ1 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells h�,�6 t ¢'same You.may use the back of this page tto provide additional well construction info
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: .1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 20.0' L''' (ft.)
For multiple Lreh,list all depths ifeliferent(example-3@200'and 1 a 100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 3.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
1f,rater level is obore casing,use"+ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 8.0 (in.) 24b. For Infection Wells:Copy toDWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER i
24c.For Water Supply and Open-Lo6p Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing ovei 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:
Permit Program,1611 MSC,Raleigh',NC 27699-1611
13b.Disinfection type: Amount: S
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018