_Well Construction - GW1_20230310 (58)

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JACOB MESSICK 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft. j
A - 4252 ft. fr.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a able)
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable irc//construction permits(i.e.1/1C,County,Stale,Variance,etc.) 0.0 ft. 35.0 ft- 2.0 in' SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 35.0 ft' 50.0 ft' 2.0 "' .010 SCH 40 PVC
❑Geothennal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft. in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEM ENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 30.0 ft' PORTLANDBENTONITE SLURRY
INMonitoring ❑Recovery ft. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK ifa licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormvvater Drainage 33.0 ft 50.0 ft. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. I ft.
❑Geothennal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soii/mck type, rain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
0.0 ft 5.0 ft. BROWN SILTY CLAY
4.Date Well(s)Completed: 02/13/23 Well ID# MW-15 5.0 ft• 50.0 ft• BROWN SILT
5a.Well Location:
JACK B QUICK STATION rt. ft.
Facility/Owner Name Facility ID#(ifapplicable) It. ft. t J LJ
108 OAKLAND AVENUE MORGANTON 28655
Physical Address,City,and Zip ft. ft.
BURKE 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-30.0-33.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one fat/long is sufficient) 22.Certification:
3SO 45' 28.85" N 810 36' 10.70" W G)1z 02/23/23
6.Is(are)the well(s): 29Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby ceriiyy that the wells)u•as(here)constructed in accordance n•ith
7.Is this a repair to an existing well: ❑Yes or MNo l.iA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
hfthis is a repair,fill out known well construction information and explain the nature ofthe ofthis record has been provided to the well owner.
repair under 1:21 remarks section or om 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 I 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: 50.0 (ft.)
For nuthip/e sreUs list al/depths ifdiJ7erent(example-3@200'and 2 a/00') Submit this GW-1 within 30 days of well completion per the following:
10. 40.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifu•aler tenet is above casing,use"+"Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
/f
11.Borehole diameter: 8.0 (in.) 24b. For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-]636
12.Well construction method: AUGER
24c.For Water Supply and Open-Loon 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
]3a.Yield(gpm) Method of test: Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018