GW1-2022-05403_Well Construction - GW1_20220311

o
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: j
JACOB MESSICK 14.WATER'ZONES
Well Contractor Name FROM TO DESCRIPTION
fr. it. ; •
A - 4252 tr. ft.
NC Well Contractor Certification Number 15.OUTER CASING for mulfi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. I in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 ft- 18.5 rt- 2.01 in. SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 18.5 ft' 38.5 ft' 2.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
Olrri ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 14.5 ft' PORTLANDBENTONITE SLURRY
TlMonitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 16.5 ft. 38.5 ft- 20-40 FINE SILICA SAND
❑Experimental Technology OSubsidence Control ft. fr.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM I TO DESCRIPTION color,hardness,soil/mck type,grain size,etc.
0.0 rr• 20.0 a• BROWN/rAN SILT
4.Date Well(s)Completed: 02/24/22 Well ID# MW-5 20.0 rt• 38.5 rr' TAN SILT
5a.Well Location: ft. ft.
BOULEVARD CLEANERS ft. fr.
+
Facility/Owner Name Facility ID#(if applicable) ft. rt. I
1510 EAST DIXON BOULEVARD SHELBY 28152 f' ft.
Physical Address,City,and Zip
i
CLEVELAND 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL- 14.5-16.5 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certification:
350 16' 22.79" N 810 30' 50.46" W Gr+tgsr� 03/01/22
6.Is(are)the well(s): INPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance wish
7.Is this a repair to an existing well: ❑Yes or (DNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis it a repair,fi//out known well construction information and explain life nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Ovee in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 38'5 (ft.)
1�ar mu/liple wells list all depths if different(example-3@200'and 2 rr 100') Submit this GW-1 within 30 days of well completion per the following:
20.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft•) Information Processing Unit,1617',MSC,Raleigh,NC 27699-1617
Ili eater level is above casing,use•'+"
IL Borehole diameter: 8.0 (in.) 24b. For Injection Wells:Copy fo DR,Underground Injection Control (IUC)
Program, 1636 MSC,Raleigh,NC 2W7699-1636
12.Well construction method: AUGER
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producin¢over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resource Revised 6-6-2018
P Q Y