GW1-2022-05406_Well Construction - GW1_20220311

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JACOB MESSICK 14.WATER ZONES
TO
Well Contractor Name
FROM
rt. rt. DESCRIPTION
i
A - 4252 rt. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. 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.U1C,County,State,Variance,etc.) 0.0 ft. 20.0 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 20.0 ft- 35.0 It. 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
❑lrrl ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 16.0 ft PORTLAND.BENTONITE SLURRY
[EMonitoring ❑Recovery
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 OStormwater Drainage 18.0 ft. 35.0 ft- 20-40 FINE SILICA SAND
❑Experimental Technology OSubsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM I TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
0.0 a• 20.0 1- BROWN/TAN SILT
4.Date Well(s)Completed: 02/23/22 Well ID# MW-4 20.0 ir• 35.0 it- TAN SILT
Sa.Well Location: ft. ft
BOULEVARD CLEANERS rt. ft.
Facility/Owner Name Facility ID9(if applicable) ft. ft.
MAR 202?
1510 EAST DIXON BOULEVARD SHELBY 28152 ft. it-
Physical Address,City,and Zip _ ft. ft.
CLEVELAND 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL- 16.0-18.0 FEET
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one fattlong is sufficient) 22.Certification:
350 16' 22.79" N 810 30' 50.46" W ICY06 oluk"I" 03/01/22
6.Is(are)the well(s)• (EPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,/hereby certify that the uvll(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 15No 15A NCAC 01C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
lfthis is a repair,fill out known well construction information and explain the nature ofthe ofthis record has been provided to the well corner.
repair under 421 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 I GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also attach additional pages ifnecessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 35.0 (ft.)
hor multiple we/Ls list a//depths iif'dierent(example-3 rci 200'and 2 a@100') Submit this GW-1 within 30 days of well completion per the following:
23.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
]0.Static water level below top of casing: (ft.) Information Processing Unit,1617iMSC,Raleigh,NC 27699-1617
If seater level is above casing,use"+"
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
(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 producinl=Iover 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
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
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