GW1-2023-00790_Well Construction - GW1_20230112

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JACOB MESSICK 14.WATER•ZONES I M
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 4252 tr. fr. 1
NC Well Contractor Certification Number ^. r.`''; a�'
j�'Y 1'S.OUTER'CASING for multLcased wells OR'LINER if a licable
GEOLOGIC EXPLORATION '^ FROM TO DIAMETER THICKNESS MATERIAL
tr. fr. 1 in.
Company Name 1
J QN 1 %r Z .1G.INNER CASING OR TUBING eothermal closed-loo'
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
r: 1
List all applicable we//construction permits(i.e.UIC,CounlX,,£tafehVai,,,iaH,Zyr,ieta)"'"°"'`_ U•0 ft- 5.0 ft- 2.0 in• SCH 40 PVC
3.Well Use(check well use): '" ft• ft. in.
17.:SCREEN I,..
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5.0 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'
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT M ETHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 2.0 ft' PORTLANDBENTONUE SLURRY
MMonitoring ❑Recovery ft. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
r 19.SAND/GRAVEL
ft.
PACK(if a licable'
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 3.0 ft• 20.0 fL 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING-LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) FROM TO DESCRIPTION color,hardness,soiVrock e, min size,etc.
0.0 ft. 10.0 ft. BROWN SILTY CLAY
4.Date Well(s)Completed: 11/29/22 Well ID# GP-13 10.0 ft- 20.0 ft- RED/BROWN SILT
Sa.Well Location: .
ft. ft.
CONVENIENCE CENTER ft. ft.
Facility/Owner Name Facility lD4(ifapplicable) ft. ft. 1
8007 PENCE ROAD CHARLOTTE 28215
Physical Address,City,and Zip ft. ft.
MECKLENBURG "2"1:REMARKS .
County Parcel Identification No.(PIN)
BENTONIfE SEAL-2.0-3.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one hit/long is sufficient) 22.Certification:
350 13' 10.10" N 800 41' 47.91" W 12/09/22
6.Is(are)the well(s)• 119Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this farm,1 hereby certify that the well(s)was(here)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,Jill out known well construction information and explain the nature of the of this record has been provided to the ii,M owner.
repair under 421 remarks section or on the back ofthis 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: 20.0
!or multiple wells list all depths ifdijjerent(example-3 rt 00'and 2 r@100') Submit this GW-I within 30 days,of well completion per the following:
10.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
f Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
/juater level is above casing,use"+"
11.Borehole diameter: 8.0 (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER 24c.For Water Supply and Open 4Loop 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
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13b.Disinfection type: Amount: i
Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources' Revised 6-6-2018