GW1-2023-00695_Well Construction - GW1_20230113

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JACOB MESSICK 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
A - 4252 y _ . .; .`'' :. ft. ft.
ti
NC Well Contractor Certification Number I I� a J ���� 15.OUTER CASING for multi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION JAN �" FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name .; _ �' 1.•fi'a
< -- ^:^'�l + 16.INNER CASING OR TUBING cother al closed-loop)
lf1'�" r '•`' '.;_; 'i FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: -
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 ft. 5.0 ft' 4.0 in. SCH 40 PVC
ft. ft. in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT S=1%1
E THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5.0 ft' 25.0 ft. 4.0 in. .020
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft, ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wells>100,000 GPD FROM TO MATERIAL Non-Water Supply Well: 0.0 . 3.0ft. PORTLANDBENTONITE
❑Monitoring ❑Recovery tt. ft.
FoAqui'fe,'r
n Well: ft. ft.
Recharge ❑Groundwater Remediation19.SAND/GRAVEL PACK ifa licabler Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMET110D
er Test ❑Stormwater Drainage 4.0 • 20.0 ft' 20-40 FINE SILICA SAND
mental Technology El Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
g/ g ) FROM ft. T50 ft- DESCRIPTION cBROWN hardness,
SILTYCLAY mm size,etc.
❑Geothermal(Heatin Coolin Return) dOther(explain under#21 Remarks)
4.Date Well(s)Completed: 12/12/22 Well ID# EW-58 5.0 ft• 25.0 fL LANDFILL TRASH
ft. ft.
5a.Well Location:
WILDERS GROVE LANDFILL ft. ft.
Facility ID# hfa licable ft. ft.
Facility/Owner Name tY (� PP )
830 CORPORATION PARKWAY RALEIGH 27610 ft. ft.
ft. ft.
Physical Address,City,and Zip
WAKE i 21.REMARKS
BENTONIfE SEAL-3.0-4.0 FEET
County Parcel Identification No.(PIN)
***EXTRACTION***
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: .
350 47' 23.68" N 780 34' 12.66" W g`�" ' 12/15/22
G.Is(are)the wcll(s): [EPcrmanent or ❑Temporary
Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or [5No 15A NCAC 02C.0100 or I5A 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 well owner.
repair under 921 remarks section or on the back ofthis form. 23.Site diagram or additional well details:
S.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: 25.0 (ft.)
For multiple wells/ist all depths ifdiJferwhl(example-3 a Z00'amd 2@100') Submit this GW-1 within 30 days of well completion per the following:
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
Ifwater level is above casing,use"+"
12.0 24b. For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER
24c.For Water Sue 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 producinu over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018