GW1--03041_Well Construction - GW1_20230310

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. I ft.
A - 4252
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a ilicable
GEOLOGIC EXPLORATION FROM TO DWMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loon)
2.Well Construction Permit#: FROM TO I DIAMETER I THICKNESS MATERIAL
List a0 applicable we//construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 ft- 39.0 !L 1..0 t"' I SCH 40 PVC
3.Well Use(check well use): 0.0 ft. 9.0 ft. 1 1.0 in. SCH 40 PVC
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS I%IATERIAL
❑Agricultural ❑Municipal/Public 39.0 ft' 44.0 ft' 1.0 t't' .010 SCH 40 PVC
❑Geotherlmal(Heating/Cooling Supply) El Residential Water Supply(single) 9.0 fr. 19.0 fL 1.0 "'' .010 SCH 40 PVC
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑trrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 2.0 ft- PORTLANDBENTONITE SLURRY
IMMonitoring ❑Recovery ft. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licablc
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO I MATERIAL I EMPLACEMENTAIETHOD
❑Aquifer Test ❑StormwaterDrainage 37.0 ft• 44.0 ft. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control 7.0 ft- 1 19.0 ft. 20-40 FINE SILICA SAND
❑Geothermal(Closed Loop) ❑Tracer 20:DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,gmin size,etc.)
0.0 ft• 5.0 ft• BROWN SILTY CLAY
4.Date Well(s)Completed: 02/08/23 Wcll ID# TMW-3 5.0 ft. 44.0 ft. BROWN/TAN SANDY SILT
Sa.Well Location: fr. ft.
BENFIELD CHEMICALS ft. ft.
k. „• .,
Facility/Owner Name Facility ID#(if applicable) fi. ft.
6108 OLD CLYDE ROAD CANTON 28716 ft. ft. MAR,
R,
Physical Address,City,and Zip ft. ft.
HAYWOOD 21.REMARKS -
County Parcel identification No.(PIN) BENTONITE SEAL-21.0-39.0 FEET&2.0-7.0 FEET
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
***NESTED WELLS***
(if well field,one lat/long is sufficient) 22.Certification:
350 32' 12.39" N 820 52' 07.51" W �¢ "P-" 02/23/23
6.Is(are)the well(s): ❑Permanent or OTemporary Signature of Certified Well Contractor Date
By signing this•fornt,/hereby certify that the ire/l(s)iras(were)consirucled in acc•ordanc•e 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
IJ'thi.s is a repair,Jill out known well construction information and explain the nature ofihe ofihis record has been provided to the well owner.
repair under 1,'21 remarks section or oil the back of this fornn.
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: 44.0/1 9.O (ft.)
Por nnihiple wells list all depths/J'dii ferenl(example-3 ct 200'aid 2 rt 100') Submit this GW-1 within 30 days of well completion per the following:
10.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.)IJ'materlere!it nbore casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 8.0 (in.) 24b. For Injection Wells:Copy to DWR,Underground Injection Control(fUC)
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 27699-1611
13b.Disinfection type: Amount:
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Forni GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018