GW1-2023-00698_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 'S i ft. ft.
ft. ft.
JAN 1 _: 2023
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased iJclls OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
o......._..:__. , _ ft. ft.
Company Name ; 5•i iL.i 16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) 0.0 ft. 5.0 ft. 4.0 '"' SCH 40 PVC
ft. in.
3.Well Use(check well use): ft.
17.SCREEN .
WeYCC Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5 0 ft. 25.0 ft' 4.0 in- .020 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft• fr. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Iiri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 3.0 ft. PORTLANDBENTONITE SLURRY
❑Monitoring ❑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 I MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 4.0 ft. 20.0 ft. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 720.DRILLING LOG attach additional sheets if necessa
FROM TO DESCRIPTION color,hardness,soil/rock e, inin size,etc.
❑Geothermal(Heating/Cooling Return) OOther(explain under#21 Remarks) 0 0 ft. S 0 ft. BROWN SILTY CLAY
4.Date Well(s)Completed: 12/12/22 Well ID# EW-55 5.0 fr. 25.0 ft. LANDFILL TRASH
ft. ft.
5a.Well Location:
WILDERS GROVE LANDFILL ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. fL
830 CORPORATION PARKWAY RALEIGH 27610 ft. ft.
ft. ft.
Physical Address,City,and Zip
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 lat/long is sufficient) 22.Certification:
350 47' 23.68" N 780 34' 12.66" W z qkto-- 12/15/22
G.Is(are)the 1ve11(s): OPermanent or ❑Temporary
Signature of Certified Well Contractor Date
By signing this form,i hereby certify that lite well(s)ryas(here)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 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 of this record has been provided to the well owner.
repair under 921 remarks section or on the back ofthis forin. 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: . 25.0 (ft.)
For nrulriple wells list all depthsifdiJferent(example-3 a��200'and 2@I00') 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 lerel 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 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-1 North Carolina Department of Environmental Quality-Division of Water Resource's Revised 6-6-2018