GW1-2021-00264_Well Construction - GW1_20210126

single
or
_.7!multiple
WELL CONSTRUCTION
lc'!�CQRD For Internal Use ONLY:
can be used f 1.Well C'.t"'t"Information.
Justin Radford 14.AVATER ZONES 2'_
FROM TO DESCRIPTION
Well Contractor Name 1 ft- 12 ft. Tan to gray sandy clay
3270 A
NC Well Contractor Certification Number 15.OUTER CASING formulh wells)OR LINER
DIAMETER
FROM TO C
MATERIAL
Geological Resources, Inc. ft. ft. in.
Company Name 16.INNER CASING:OR,, BINGf(i6theirinni -1060Y11-
cl4w
WM0701239 FROM I TO DIAMETER -1-THICKNESS I MATERIAL
2.Well Construction Permit#:
List all applicable well permits(i.e.County,Stale,Variance,Injection,etc.) 0 1 2 1 2" "' PVC
I SCh 40 1
in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ClAgricultural oMunicipal/Public 2 ft' 110 ft. 2 "' 1 0.010 SCh 40 PVC
[]Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) in.
z
11 Industrial/Commercial 0 Residential Water Supply(shared) 18.GROU_T
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Olrrigation 0 ft' 0.5 ft- Concrete Pour
Non-Water Supply Well: 0.5 1.0 bentonite Pour
Monitoring 0 Recovery
Injection Well:
OAquifer Recharge DGroundwater Remediation 19.-SAND/GRAVEL-PAC-K ifAiipli6b]e)I
FROM TO MATERIAL EMPLACEMENT METHOD
[]Aquifer Storage and Recovery Ei Salinity Barrier 12 Sand Pour
CAquifer Test oStormwater Drainage
OExperimental Technology oSubsidence Control 20.DRILUING1,"OG(A tti�'c wditi"alsheetsifnic6ga
DGeothermal(Closed Loop) C]Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
DGeothermal(Heating/Cooling Return) 00ther(explain under#21 0 rt. ft. Tan sandy clay
4.Date Wells)Completed: 01/05/2021 Well ID#MW-C 4 12 Direct push-, no recovery
5a.Well Location:
CB Jones Texaco N/A
Facility/Owner Name Facility ID#(if applicable)
NC Route 42 and SR 1321, Powellsville, NC 27967
Physical Address,City,and Zip :21.-REMARKS
Bertie 6910-07-0329
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one latAong is sufficient)
36.225643 N76.932432 -W 01/08/2021
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or OTemporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: C]Yes or E!lNo copy ofthis record has been provided to the well owner.
If this is a repair,fill out known well consiniction information and explain the nature of the
repair tinder#21 remarks section or on the back ofthisforin. 23.Site diagram or additional well details:
1 You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you cam
submit oneforin. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 10 -(ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths itdifferent(example-3@200'and 2@100) ponOction to the following:
10.Static water level below top of casing: 0.42 'U Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 3.5 (in.) JAN 2 For infection Wells ONLY: In addition to sending the form to the address in
rlrr,,.0 ,�4�,4 qNj)qj1Wsci submit a copy of this form within 30 days of completion of well
Hand Auger/Direql s,.,h n o r,z �1%,
12.Well construction method: Z'0 - s ction to the following:
(i.e.auger,rotary,cable,direct push,etc.) Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply&Injection Wells
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013