_Well Construction - GW1_20230310 (59)

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JACOB MESSICK 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
A - 4252
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER it a licable)
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 well construction permits(i.e.U1C,County,State,Variance,etc) 0.0 ft- 35.0 ft- 2.0 tn' 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' 50.0 rt. 2.0 "' 1 .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) El Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri anon ❑Wells> 100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 30.0 ft' PORTLANO BENTONITE SLURRY
(EMonitoring El Recovery tr. ft.
Injection Well:
rr. et.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑StormwaterDrainage 33.0 rr• 50.0 rt• 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,soil/rock type,grain size,etc.)
0.0 rt• 5.0 ft. BROWN SILTY CLAY
4.Date Well(s)Completed: 02/14/23 Well ID# MW-5A 5.0 e. 50.0 tt. BROWN SILT
5a.Well Location: ft. tr. -••- -
JACK B QUICK STATIONaq `. .'
Facility/Owner Name Facility lD#(irapplicable) ft. ft. MAR
108 OAKLAND AVENUE MORGANTON 28655 ft. ft.
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]at/long is sufficient) 22.Certification: ��"" �
350 45' 28.36" N 810 36' 10.50" W ;mow 02/23/23
6.Is(are)the well(s): [EPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this farm,1 hereby certify that the wel/(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
!f this is a repair,fill out known well construction injornation and explain the nature of the of this record has been provided to the we/I owner.
repair under 921 remarks section or on the back of Ntis•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 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.)
1--or multiple wells list all depths ifdii ferem(example-3 a 00'and 2 c@r 100')10. Submit this GW-1 within 30 days of well completion per the following:
40.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
fwater level is above casing,use"+"Static water level below top of casing: (ft.) Information Processing Unit,1617 NISC,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 27699-1636
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
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1 61 1
13b.Disinfection type: Amount:
Form GW-I Notch Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018