GW1--03043_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. ft.
A - 4252
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable'
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 permiis(t.e.U1C,County,Stare.Variance,etc.) 0•0 ft- 40.0 f- 1.0 in- SCH 40 PVC
3.Well Use(check well use): 0.0 ft- 5.0 ft- 1.0 in' SCH 40 PVC
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE. THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 40.0 ft' 45.0 ft' 1.0 '"' .010 SCH 40 PVC
❑Geothermal(Heating/CoolingSupply) ❑Residential Water Supply(single) 5.0 ft. 20.0 ft' 1.0 1" .010 SCH 40 PVC
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 2.0 ft' PORTLAND BENTONITE SLURRY
f!lMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifeit Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Stonnwater Drainage 38.0 fit- 45.0 ft- 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control 4•0 ft- 22.0 1" 20-40 FINE SILICA SAND
❑Geotherlmal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM M ft. S T O 1t•
DESCRIPTION(color,BROWN
s,soil/rock type,SILTY CLAY t,un size,etc.)
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks)
4.Date 1Vell(s)Completed: 02/07/23 Well ID# TMW-1 5.0 ft- 45.0 ft BROWN/TAN SANDY SILT
<:
fia.Well Location: ft. ft. fT> r
BENFIELD CHEMICALS --
Facility/OwnierNane Facility ID#(ifapplicable) ft.- ft. MAR ;, ID Z023
6108 OLD CLYDE ROAD CANTON 28716 ft. ft.
Physical Address,City,and Zip ft. ft.
HAYWOOD '21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL^-22.0-38.0 FEET&2.0-4.0 FEET
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
***NESTED WELLS***
(ifwell field,one lat/long is sufficient) 22.Certification:
350 32' 12.39" N 820 52' 07.51" W 02/23/23
6.Is(are)the well(s): ❑Permanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)u•as(were)cons•iracled 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 Construciiot Standards and Iitot a cope
lfthis is a repair,fill out known well construction itJbrnnation and explain the nature ofthe ofihis record has•been prorided to the sPe/I owner.
repair under t21 remarks section or on the back of'this•fora.
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: 45.0/20.0 (ft.)
Fornnihiple wells/is/all depths ffeli/ferew(example-3@200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 10.0 (ft) 24a, For All Wells: Original form to Division of Water Resources (DWR),
Ifwaier level is above 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 (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(gpnl) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-161 I
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018