GW1-2023-00697_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 ft. fr.
A - 4252
ft.
NC Well Contractor Certification Number '•=- i1 v.i l ,.,'4
15.OUTER CASING for multi-cased wells OR LINER if a tlicable
�ti FROM TO DIAMETER THICKNESS MATERIAL
GEOLOGIC EXPLORATION
J A i�! 2072
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
I�ti�3i.1:. .,j ii.I FROM TO DIAMETER rTHIKNESSAL
2.Well Construction Permit#:List all applicable well constructionpermits ri.e.UIC,Couniy,�$talerirariaribe,etc.) 0.0 t. 5.0 ft' 4.0 'n• 40 PVC
rr.3.Well Use(check well use): rt. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5.0 fr• 25.0 ft' 4.0 "' 1 .020 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fr. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) is.GROUT
❑Irri ation ❑Wells>100,000 GPD 119.
ROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: .0 ft. 3.0 ft. PORTLAND BENTONRE SLURRY
❑Monitoring ❑Recovery rr. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage 4.0 ft- 20.0 ft- 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM ft- T5.0 ft. DESCRIPTIONcBROuVN SILTY CLAY
olor,hardness,soit/mck type, ram size,etc.
❑Geothermal(Heating/Cooling Return) OOther(explain under 421 Remarks)
4.Date Well(s)Completed: 12/12/22 Well ID# EW-56 5.0 1" 25.0 ft' LANDFILL TRASH
ft. ft.
Sa.Well Location:
WILDERS GROVE LANDFILL ft. ft.
Facility/Owner Name Facility ID#(if applicable)
ft.
830 CORPORATION PARKWAY RALEIGH 27610 fr ft.
ft.Physical Address,City,and Zip ft.
WAKE 21.REMARKS
BENTONITE 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[at/long is sufficient) 22.Certification:
350 47' 23.68" N 780 34' 12.66" W 12/15/22
6.Is(are)the well(s): Permanent or ❑Temporary
Signature of Certified Well Contractor Date
By signing this form,l hereby certify that the wells)was(mere)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or nNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If ilds is a repair,fi/I out known well construction information and explain the nature of the ofthis record has been provided to the we/l owner.
repair under 421 remarks section or on the back ofthis fora. 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: 25.0
For multiple wells list all depths li'diJferen!(example-3@200'and 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
If water level is above casing,use"+"
2.0 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 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
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018