GW1-2022-03244_Well Construction - GW1_20220314

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information:
JACOB MESSICK 14.WATER ZONES ! `
Well Contractor Name FROM TO DESCRIPTION
A - 4252
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased wells OR LINER if a licsble
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. 1 I :in.
Company Name
16.INNER CASING OR TUBING eothermal 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- 25.0 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 OMunicipal/Public 25.0 ft• 40.0 ft' 2.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. im
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri atlon ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 20.0 rt' PORTIANDBENTONITE SLURRY
OMonitoring ❑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 ❑Stormwater Drainage 23.0 ft• 40.0 ft' 20-46 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/imck type,gimin sin,etc.
0.0 ft- 10.0 ft. BROWN SILTY CLAY
4.Date Well(s)Completed: 01/1 3/22 Well ID# MW-4 10.0 ft- 40.0 ft- BROWN/TAN SILT
5a.Well Location: ft. ft.
KIMS CLEANERS ft. ft. 1
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
250 SOUTH MAIN STREET MOORESVILLE 28115
Physical Address,City,and Zip
IREDELL 21•REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-20.0-23.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IaUlong is sufficient) 22.Certification:
350 34' 49.17" N 800 48' 54.17" W 02/21/22
6.Is(are)the well(s): TPermanent or ❑Temporary Signature ofCertified Well Contractor Date
By signing this farm,I hereby term thai'the well(s)was(were)constructed in accordance frith
7.Is this a repair to an existing well: ❑Yes Or [5No 15A NCAC 01C.0100 or 15A NCAC 01C.0100 Well Construction Standards and that a copy
//'this is a repair,Jill out known well construction information and explain the nature of the of this record has been provided in the well owner.
repair under till remarks section or on the hack ofthis firm.
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 Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 40.0
For multiple wells list al/depths tfdii ferew(example-3 rt 00'and 1@/00') Submit this GW-1 within 30 daysjof well completion per the following:
35.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ftJ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lfwater level is above casing,use"+"
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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 producing over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: I
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13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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