GW1-2022-07415_Well Construction - GW1_20220530

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JACOB MESSICK M'
:14:°Wi1TERZONES.' `
Well Contractor Name FROM TO DESCRIPTION
A - 4252 ft. ft.
NC Well Contractor Certification Number
7 ft. ft.
y .. ) :15.OUTE&.CASING for.multi-cased wells O&LINER ifa livable
GEOLOGIC EXPLORATION r% FROM TO DIAMETER THICKNESS MATERIAL
p 0 ton ft. ft. in.
Company Name MN
16.INNER CASING OR`TUBING' eo`thermal cldsed-Ioo
2.Well Construction Permit#: _ t R UK FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,) gfi p a^ ) 0.0 11- 3.0 ft.
2.0 1O SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 3,0 IL 13.0 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)
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT-
Non-Water Supply Well: 0.0 ft' 1.0 ft PORTMD BENTONNE SLURRY
OMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL'PACK
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 2.0 ft- 13.0 1" 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer f20 DRILLINA LOG attacti additioua`sheets,f necessa - -
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 021 Remarks) FROM To DESCRIPTION color,hardness,soil/mck a rain size,etc.
0.0 ft- 13.0 ft- TAN SILTY SAND
4.Date Well(s)Completed: 04/25/22 Well ID# MW-7 ft. ft.
5a:Well Location: ft. ft.
SPEEDWAY- 8187 ft. ft.
- ft. ft.
Facility/Owner Name Facility ID#(if applicable)
14477 US - 17 HAMPSTEAD 28443 ft. ft.
Physical Address,City,and Zip
ft. ft.
PENDER zr.REMARxs.. :-
County Parcel Identification No.(PIN) BENTONITE SEAL-1.0-2.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sufficient) 22.Certification:
34o 21' 54.50" N 77o 42' 49.35" W ►
05/10/22
6.Is(are)the well(s): 191'ermanent or ❑Temporary Signature ofCertified Well Contractor Date
By signing this form,l hereby certify that the well(s)was(were)constructed in accordance ivith
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information and explain the nature ofthe ofthis record has beenprovided to the well 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 Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 13.0 (ft.)
For multiple wells list all depths if different(example-3@200'and 2@100� Submit this GW-1 within 30 days of well completion per the following:
6.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifivaier level is above casing,use"+"
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:
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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