GW1-2022-03247_Well Construction - GW1_20220314

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: [�-
JACOB MESSICK 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. k
A - 4252 ft. ft.
rt-
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. I ft. I ' ,in.
Company Name
g
,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- 30.0 ft- 2,0 I 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 30.0 rt• 45.0 ft' 2.0 in' .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
i
❑Industrial/Commercial ❑Residential Water Supply(shared) 18 GGROUT
❑Irrl ation ❑Wel Is> 100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 24,0 ft- PORTLANDaENTONFE SLURRY
TIMonitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK ifa livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑StormwaterDrainage 28.0 rL 45.0 fr, 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 40.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,gmin sim,etc.
0.0 ft. 10.0 ft. BROWN SILTY CLAY
4.Date Well(s)Completed: 01/12/22 Well ID# MW-1 10.0 ft- 45.0 ft- BROWNITAN SILT
5a.Well Location: ft. ft.
KIMS CLEANERS ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
250 SOUTH MAIN STREET MOORESVILLE 28115 rt. rt. 202�
Physical Address,City,and Zip ft. ft.
IREDELL 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL'-24.0-28:0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
3SO 34' 49.17" N 800 48' 54.17" W 16*16 0" 02/21/22
6.Blare)the well(s): MPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,/hereby certify that the well(s)was(were)constructed in accordance with
7.is this a repair to an existing well: ❑Yes or MNo 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
(/.this is a repair,fill out known we//construction information and explain the nature ofthe of this record has been provided to the srcll owner.
repair under#11 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 Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 45.0
For multiple wells list all depths ifdiifferent(example-3 a 100'and 1 c@r 100') Submit this GW-1 within 30 days:ofwell completion per the following:
10.Static water level below top of casing: 35.0 (ft) 24a. For All Wells: Original form,to Division of Water Resources (DWR),
If,varer level is above casing,use"+ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
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: E `
24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1 61 1
13a.Yield(gpm) Method of test: 6r
13b.Disinfection type: Amount: t
i.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources[ Revised 6-6-2018