GW1-2021-00265_Well Construction - GW1_20210126

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Justin Radford 14.NVATERZONEs
FROM TO DESCRIPTION
Well Contractor Name 8 ft- 12 ft. Gray sandy clay
3270 A ft. I ft.
NC Well Contractor Certification Number 15.OUTER CASING for mulh cased Wells OR`LINER°f:a"lica`tile ,,„;*„ .
FROM TO DIAMETER- THICKNESS MATERIAL
Geological Resources, Inc. rt. ft. in.
Company Name '16.'INNER,CASING,OR�UBING edthermalclosed-lo6p)
WM07012237 FROM TO DIAMETER THICKNESS MATERIAL
-
2.Well Construction Permit#: 0 ft. 2 ft. 2" i" sch 40 1 PVC
List all applicable well permits(i.e.County,State, Variance,Injection,etc)
ft. ft. in. _
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 2 'L 12 tt. 2 in. 0.010 sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. rt. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) `18.CROUT :r�
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 ft. 0.5 ft. Concrete Pour
Non-Water Supply Well:
0.5 ft- 1.0 ft- Bentonite Pour
❑Monitoring @Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK:if a licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 1 tt. 12 ft• Sand Pour
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING li0G•attach addiiitinali"sheets if<necessa`
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soivrock t�type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 ft. 10 ft. Tan medium sand
4.Date Well(s)Completed: Well ID#
12/18/2020 MW-1 R 10 ft- 12 ft. Gray sandy clay
ft. rt.
5a.Well Location: ft. ft.
Hoggard's Grocery 0-023897 ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1235 Bull Hill Road, Windsor, NC
Physical Address,City,and Zip 21.REMARKS i
Bertie 6825-77-1145
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one IatAong is sufficient)
36.086578 N 76.877521 W tQ oy� 01/08/2021
Signature of Certified Well Contractor Date
6.Is(are)the well(s): 2Permanent or ❑Temporary By signing this form, 1 hereby certify that the wells)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy ofthis record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under u21 remarks section or on the back ofthis form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 1 ;"4; +construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same coastru rtrll1;yo ct5ri`
submit one form. e� SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 12 JAN(f%n2W r All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths lfdiJferent(example-3@200'and 1@100') cotlstructigtt to the Following:
p 1191 vvrr'31i4117PTO •3`; J U��ii
10.Static water level below top of casing: 8.31 111 ) •CCt°Oip Division of Water Resources,information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
n
11.Borehole diameter: 6 (in.) 24b.For Infection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: 6 Steel Flight Auger construction 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-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013