GW1-2022-06936_Well Construction - GW1_20220601

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JACOB M ESSICK 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 THICKNESS if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM I TO I DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 ft. 68.0 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 68.0 ft' 88.0 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>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 64.0 ft' PORTIANDBENTONnE SLURRY
❑Monitoring ❑Recovery ft. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation ft. ft.
19.SANDIGRAVEL-PACK if applicable)
"
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 66.0 ft. 88.0 ft. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) CJOther(explain under#21 Remarks) FROM To I DESCRIPTION color,hardness soii/mck type,grain sire,etc.
0.0 ft. S.0 ft. BROWN SILTY CLAY
4.Date Well(s)Completed: 04/08/22 sell ID# PZ-6-7 5.0 ft. 20.0 ft. BROWN/TAN SILT
5a.Well Location: 20.0 it' 88.0 It' BROWN/TAN SILTY PWR
WILKES COUNTY LANDFILL ft. ft. Y,� k
Facility/Owner Name Facility ID#(if applicable)
9219 ELKIN HIGHWAY ROARING RIVER 28669 ft. ft. ® � 2�2,_
Physical Address,City,and Zip
ft. ft.
WILKES 21.REMARKS
County Parcel Identification No.(PIN) BENTONIfE SEAL-64.0-66.O,FEETr,; ;:,•�'n=�'`''` -
***PIEZOMETER***­
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
360 12' 27.47" N 800 59' 24.00" W ti'td�i 04/21/22
6.Is(are)the well(s): I9Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)ivas(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out lnrown 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 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: 88.0 (ft.)
For multiple ivells•list all depths ifdierent(example-3@200'and 2@100) Submit this GW-1 within 30 days of Well completion per the following:
40.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
If
f water level is above casing,use"+"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
Permit Program,1611 MSC,Raleigh,NC 27699-1
13a.Yield(gpm) Method of test: 6 1 1
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018