GW1-2023-00783_Well Construction - GW1_20230112

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JACOB MESSICK 14.WATER ZONES, i
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 4252 „_> �r, �, M t 5
ft. ft.
NC Well Contractor Certification Number t~ •� •'" ••<y �t A� •z'
15.OUTER CASING for multi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION Ink; A C �(��� FROM TO DIAMETER THICKNESS MATERIAL
J A NI t' 0.0 ft 30.0 ft. 6.0 j SCH 40 PVC
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: lit`'D�: ?T` nat_ng Ufrhi FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Countj+%5;=,M%MdhZe,etc.) 0.0 ft- 35.0 ft- 2.0 in. 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 35.0 ft' 40.0 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
❑Irrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 28.0 ft- PORTLANDBENTONITE SLURRY
I!flMonitoring ❑Recovery 0.0 ft- 30.0 ft- PORTLANDBENTONITE SLURRY
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 33.0 ft- 40.0 ft. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) I FROM I TO DESCRIPTION color,handness,soil/mck type,gnin size,etc.
0.0 ft• 25.0 ft- BROWN CLAY
4.Date WeII(S)Completed: 12/02/22 Well ID# DW-1 25.0 ft• 35.0 fL BROWN/TAN SAND
Sa.Well Location: 35.0 ft• 40.0 1t' TAN SANDY CLAY
CIRCLE K - 2723019 ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. I h
400 ERWIN ROAD DUNN 28334 ft. ft.
Physical Address,City,and Zip ft. ft.
HARN ETT :21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-28.0-33.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
350 18' 56.00" N 780 37' 34.17" W i '017.4� 12/09/22
6.Is(are)the well(s)• RPermanent or ❑Temporary Signature of Certified Well Contractor , Date
By signing this form,I hereby certify that the well(s)was(here)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo I5A 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 tinder#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-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: 40.0 (ft.)
1•br multiple wells list all depths%it dli fcrent(example-3 200'and 2@I00) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 15.0 (ft.) Information
For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
IJlroter level is above casing,use
11.Borehole diameter: 1 2.0/5.875 (in) 24b.For Infection Wells:Copy to DWR,Underground Injection Control (IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER/MUD ROTARY
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:
Fonn GW-1 North Carolina Department of Environmental Quality-Division of Water Resources) Revised 6-6-2018
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