GW1-2022-06946_Well Construction - GW1_20220601

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JACOB MESSICK WATER ZONES
Well Contractor Name FROM ft. TO DESCRIPTION
ft.
A - 4252
ft. ft.
NC Well Contractor Certification Number :15.OUTER CASING for multi-cased'wells OR LINER a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. is
Company Name '16.INNER CASING OR TUBING eother at closed-loop)'
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 ft. 30.0 ft. 2.0 in- SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: i17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 30.0 f" 35.0 ft' 2.0 i- .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 26.0 ft' PORTLANDBENTONrrE SLURRY
[EMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK ifa licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 28.0 ft. 35.0 ft. 20-40 FINE SILICA SAND
❑Experimental Technology El Subsidence Control ft. ft.
❑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 soilfrvcktype rain size,etc
0.0 ft• 26.0 ft TAN SILTY SAND
4.Date Well(s)Completed: 04/26/22 well ID# MW-4D 26.0 ft- 28.0 ft. SANDY CLAY
5a.Well Location: 28.0 It. 35.0 ft' FINE TAN SILTY SAND
SPEEDWAY- 8187 fr. fr.
Facility/0wnerName_ FacilitylDN(if applicable) fr. ft.- --
14477 US - 17 HAMPSTEAD 28443 ft. ft. jU �
Physical Address,City,and Zip ft. ft v
PENDER `21.REMARKS s-. ; P -
County Parcel Identification No.(PIN) BENTONITE S'EAL�a; 6;Q; Z8:0;F,EET�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
340 21' 54.50" N 770 42' 49.35" W 05/10/22
6.Is(are)the well(s): 29Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(ivere)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or INNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known ivell construction information and explain the nature of the ofthis record has been provided to Cite ivell owner.
repair under rl21 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 I 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: 35.0 (ft.)
For multiple ivells list all depths ifdifferent(example-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
10.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ijivater level is above casing,use"+"
f Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 276994617
11.Borehole diameter: 12.0/5.875 (in) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
AUGER/MUD ROTARY Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 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
NC 2769 - 6111
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018