GW1-2022-08412_Well Construction - GW1_20220527

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
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINERlicable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS M1tATER1AL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,Stare,Variance,etc) 0.0 1t. 10.0 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 10.0 ft. 45.0 It' 2.0 in- .010 SCH 40 PVC
❑GeotlTermal(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. 4.0 ft. PORTLANDBENTONITE SLURRY
Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 8.0 ft- 45.0 1t. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑GeotlTermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.)
0.0 1t. 1.0 ft. CONCRETE/STONE
4.Date Well(s)Completed: 03/1 1/22 Well ID# MW-1 1.0 ft. 20.0 ft. BROWN SILTY CLAY
5a.Well Location: 20.0 1t. 45.0 ft' BROWN SILT
BENJAMIN BROWN PROPERTY fr. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
1225 NORTH LIBERTY STREET WINSTON SALEM 27101 ft. ft.
Physical Address,City,and Zip
ft. ft.
FO RSYTH 21.REMARKS
County Parcel Identification No.(PIN) BENTONIfE SEAL-4.0-8.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iatflong is sufficient) 22.Certification:
360 06' 37.25" N 800 14' 04.38" W :6 o'W-lt, 03/15/22
6.ls(are)the well(s): MPermanent or ❑Temporary Signature ofCertified Well Contractor Date
By signing this form,1 hereby certify that the srel/(s)sros(here)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
Ifthis is a repair,fill out known well construction information and explain the nature ofthe ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back of7his form. 23.Site diagram or additional well details: Dill
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide Dill well construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Ove?in Remarks Box).You may also attach additional pages if necessary.�j
drilled: 24.SUBMITTAL INSTRUCTIONS NIM 2 i 20232
9.Total well depth below land surface: 45.0 (ft.)
l•br nmdtiple ire/Is list all depths ifdiijferent(example-3@200'and 2 a 100') Submit this GW-1 within 30 days of well completion per the following:
20•0 24a. For All Wells: Original form to Division of Water Resources (DWR),
f u�nrer level is above casing,use"+Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
1f "
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