GW1-2022-07416_Well Construction - GW1_20220530

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JACOB MESSICK14:wATERzoNEs_° .
Well Contractor Name FROM TO DESCRIPTION
A - 4252 -" �+ ft. ft. 1
NEE m m
NC Well Contractor Certification Number '15.OUTER CASING for multi-cased,wells OR LINER if a licable
GEOLOGIC EXPLORATION MAY 3 0 2022 FROM TO DIAMETER THICr�VESS MATERIAL
ft. I ft. I in.
Company Name k>wrnaaan Prau5*--+'n9 Unit ''.16.INNER CASING OR TUBING "eothermat closed-loop)
2.Well Construction Permit#: [Aa"QgSOG FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 It- 3.0 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 I THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public . 3.0 ft. 13.0 It" 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
❑hTi ation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 It' 1.0 ft' PORTLANDBENTOWE SLURRY
Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 2.0 ft. 13.0 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) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc
0.0 ft- 13.0 ft. TAN SILTY SAND
4.Date Well(s)Completed: 04/25/22 well ID# MW-6 ft. . ft.
Sa.Well Location: ft. ft.
SPEEDWAY - 8187 ft. ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
14477 US - 17 HAMPSTEAD 28443 ft. ft.
Physical Address,City,and Zip ft. ft.
PENDER 21.REMARKS°
County Parcel Identification No.(PIN) BENTONITE SEAL-1.0-2.0 FEET
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 td , 05/10/22
6.Is(are)the well(s): [EPermanent 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 known well construction information and explain the nature of the ofthis record has been provided to the ivell owner.
repair under#21 remarks section or on the back ofthis 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 ifdierent(example-3@200'and 1@1001 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),
Ijwater 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 in
FOR WATER SUPPLY WELLS ONLY: 24d.For Water We11S roducin 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:
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources!
Revised 6-6-2018
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