GW1-2022-06934_Well Construction - GW1_20220601

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. 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 THICKNESS MATERIAL
ft. ft. in
Company Name
16.INNER CASING OR TUBING eothermal closed-loon)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable spell construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 ft• 75.0 ft- 2,0 "' 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 75.0 f" 90.0 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
❑Irrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft' 70.0 ft' PORTLANDBENTONnE SLURRY
❑Monitoring ❑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 I EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 73.0 ft- 90.0 1- 20-40 FINESILICASAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Heating/Cooling Return) InOther(explain under 421 Remarks) FROM TO DESCRIPTION color,hardness,soiUmck type,grain size,etc.
0.0 ft- 5.0 ft- BROWN SILTY CLAY
4.Date Well(s)Completed: 04/1 1/22 Well ID# PZ-6-6D 5.0 ft- 60.0 ft- BROWNffAN SILT
5a.Well Location: 60.0 ft- 90.0 ft. BROWN/TAN SILTY PWR
WILKES COUNTY LANDFILL ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. -
9219 ELKIN HIGHWAY ROARING RIVER 28669 ft. ft,
Physical Address,City,and Zip ft. ft.
WILKES 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-70.0-AV kE
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
***PIEZOMETER***
(ifwell field,one lat/long is sufficient) 22.Certification:360 12' 27.47" N 800 59' 24.00" ;�i W '�. ono-$" 04/21/22
6.Is(are)the well(s): (Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the svell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fell out known spell construction information and explain the nature ofthe ofthis record has been provided to the spell 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: 90'0 (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:
10.Static water level below top of casing: 60.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If ivater 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: 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 27699-1 6 1 1
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018