_Well Construction - GW1_20230310 (60)

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 ft. ft.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#' FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 ft. 35.0 ft. 2.0 1°' SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
17.
Water Supply Well: FRONT SCREENTO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 35.0 ft. 50.0 ft' 2.0 in- .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft in.
Olndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
01rr1 ation ❑Wells>100,000 GPD FRONT TO MATERIAL EMPLACEM ENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 30.0 ft' PORTLANDBENTONITE SLURRY
MMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK ifa livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FRONT TO MATERIAL I ENIPLACEMENTDIETHOD
❑Aquifer Test ❑Stormwater Drainage 33.0 ft. 50.0 ft. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM B
f ft. TO
g, DESCRIPTION cR01WNsSILTYCLAY s,sitillrock type, , insim,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
4.Date Well(s)Completed: 02/14/23 Well ID# MW-1 R 5.0 ft. 50.0 rt. BROWN SILT.^_
ft. ft. .. , .,...
5a.Well Location: -
JACK B QUICK STATION. fr. rt. , 4' y � LCZ3
Facility/Owner Name Facility ID81(ifapplicable) ft. ft.
fi-
108 OAKLAND AVENUE MORGANTON 28655 ft.
Physical Address,City,mid 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/secondsor decimal degrees:
(ifsvell field,one latllong is sufficient) 22.Certification:
350 45' 28.19" N 810 36' 10.20" W d� G)tito-� 02/23/23
6.Is(are)the well(s): MPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the ivell(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
1f this•is a repair,fill out known ire//construction information and explain the nature of the ofthis record has been provided to the well owner.
repair under 921 remarks section or at the back ofthis form.
23.Site diagram or additional well details:
8.For Gcoprobe/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 multiple wells list all depths ifd/fferent(example-3 a 200'and 2 n 100') 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),
f u•aterlerulisaborecasing,use"+"Static 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 (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 tlTe
(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-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018