GW1-2022-06438_Well Construction - GW1_20220527

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JACOB MESSICK 14 WATERZONES .'
Well Contractor Name FROM TO DESCRIPTIONft. ft.
A - 4252 ft. ft.
NC Well Contractor Certification Number 15."OUTER CASING'for multi-cased-wells OR LINER if a `licable
GEOLOGIC EXPLORATION FROM TO DIAMETER TRICKINESS MATERIAL
ft. ft. in
Company Name
16.INNER CASING OR TUBING eothermal closed-loo
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- 17.0 ft. 2,0 tO 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 17.0 ft, 22.0 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
❑hrl ation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 13.0 ft- PORTLANDBENTONRE SLURRY
OMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
❑A Aquifer Storage and Recovery ❑Salim Barrier FROM SAND/GRAVEL PACK MATE'IAble`-
q g ry ty FROM TO MATERIAL I EMPLACEMENT METHOD�
❑Aquifer Test ❑Stormwater Drainage 15.0 ft. 22.0 ft- 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer ,20.DRILLING L,OG'attach additional sheets if necessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM I TO DESCRIPTION(color,hardness,soil/rock type, fain size;etc.
0.0 it- 22.0 ft- RED/BROWN SILTY CLAY
4.Date Well(s)Completed: 05/13/22 sell ID# PZ-6 ft. ft.
Sa.Well Location:
ft. ft.
LAKE MICHAEL DAM ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
LAKE MICHAEL PARK ROAD MEBANE 27302 ft. ft.
Physical Address,City,and Zip ft. ft.
ALAMANCE 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL- 13.0-15.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
360 06' 27.12" N 790 15' 02.21" �r 6 4vla� 05/27/22
6.Is(are)the well(s): 0flPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certijy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 1ENo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under 921 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 additio®a ill 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 MAY 2 7 2022
9.Total well depth below land surface: 22.0 (ft)
For multiple wells list all depths ifdierent(example-3(@ 200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original fort to Division of Water Resources (DWR),
If water level is above casing,use"+"
f Static water level below top of casing: (ft.) 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: 24d.For Water Wells producing over 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:
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Foam GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018