GW1-2022-07417_Well Construction - GW1_20220530

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 •� g6 ft. ft.
NC Well Contractor Certification Number '�e I=_D
15.OUTER CASING for multi-cme&wells'OR LINER if a licable
GEOLOGIC EXPLORATION AA(tV (� �022 FROM TO DIAMETER THICKNESS MATERIAL
MAY v ft. ft. is
Company Name
pm„C, 16.INNER CASING ORTUBING eothermalclosed-loo
2.Well Construction Permit#: ItlfOfiTiL1 ! L. �svF✓YC(J L1tTp FROM TO DIAMETER THICKNESS MATERIAL
List all applicable ivell construction permits#.e.UIC,County , .rtance,etc.) 0.0 ft- 3.0 IL 2.0 rn SCH 40 PVC
3.Well Use(check well use): ft. ft. 9n.
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 3.0 ft' 13.0 fL 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 `
❑Irr( ation []Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 IL 1.0 It' PORTLANDBENTONITE SLURRY
MMonitoring ❑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 EMPLACEMENT METHOD
El Aquifer Test ❑StormwaterDrainage 2.0 It- 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/mck rain size,eta
0.0 ft• 13.0 ft• TAN SILTY SAND
4.Date Well(s)Completed: 04/26/22 Well ID# MW-8 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"=_. '.'V"".",'
County Parcel Identification No.(PIN) BENTONIfE SEAL-1.0-2.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
34e 21' 54.50" N 77e 42' 49.35" ter . 4pu�"" 05/10/22
6.Is(are)the well(s): INPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the wells)ivas(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 01C.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 of this record has been provided to the ivell 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-I 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 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),
Ifi f Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
valer 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 27699-1611
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018