GW1-2023-00780_Well Construction - GW1_20230112

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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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 LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER I THICKNESS MATERIAL
ft. ft. I I -in.
Company Name
16.INNER CASING OR TUBING eothermal closed-too
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable me/l construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 ft. 10.0 ft. 2.0 t"' SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
17.SCREEN.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 10.0 ft• 20.0 ft. 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
❑1RI ation ❑Wells>1QO,pD.O GPD, l'^^ --FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: e 5 ii� 0.0
t ,v.i:v ft. 4.0 ft' PORTLAND aENTONRE SLURRY
MMonitoring El Recovery ft. ft.
Injection Well: JAN 1 2 Z073 ft.
❑Aquifer Recharge ❑Groundwater Remediation
I!` ,SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinit�f$a.Srie[;:�1 i l` T FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrairiage" t'J 80 ft. 200 ft. 20-40 FINESILICASAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soil/rock e, inin sin,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
0.0 It. 10.0 ft. BROWN/RED CLAY
4.Date Well(s)Completed: 12/02/22 Well ID# MW-4 10.0 ft. 20.0 ft. BROWN SANDY CLAY
Sa.Well Location: ft. ft. '
CIRCLE K - 2723019
Facliity/Owner Name Facility ID#(if applicable) ft. fL r -
400 ERWIN ROAD DUNN 28334 ft. ft.
Physical Address,City,and Zip ft. ft.
HARN ETT 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 fat/long is sufficient) 22.Certification:
350 18' 56.00" N 780 37' 34.17" W '14" 01W." 12/09/22
6.Is(are)the well(s)• INPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby terrify that the ivell(s)ivas(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or IMNo 15A NCAC 01C.0100 or 15A NCAC OiC.0200 Well Construction Standards and that a copy
If this is a repair,fill out known ire/l construction information and explain the nature oflhe ofthis record has been provided to the irell 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 Ovet'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 20.0 (ft.)
For multiple wells list all depths/fd fferent(example-3 rJ 00'and 1Q100') Submit this GW-1 within 30 days of well completion per the following:
15.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
f water is above casing,arse Stalk water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If "+"
11.Borehole diameter: 8.0 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(lUC)
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:
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13b.Disinfection type: Amount:
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Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018