GW1-2021-00266_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.'*VATERZONES`' "
FROM TO DESCRIPTION
Well Contractor Name 0.6" ft• 12' ft.-I tan to gray silty clay
3270 A ft. ft.
NC Well Contractor Certification Number 15.OUTER,CASING fo'ir hl*=cased wells'OR=LINER`ifa "livable
FROM TO DIAMETER THICKNESS MATERIAL
Geological Resources, Inc. rt. ft. I in.
Company Name 16ANNEWCASING OR,T_UBING &othermal closed-looms �'
WM0701238FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft, 2 ft. 2" in. sch 40 PVC
List all applicable well pernvits(i.e.County,State, Variance,Injection,etc)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN a
Water supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 2 ft 12 ft• 2 in. 0.010 sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) tt. tt. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM .TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 rt. 0.5 rt. Concrete Pour
Non-Water Supply Well:
SMonitoring ❑Recovery 0.5 ft• 1.0 R• Bentonite Pour
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ifiNlicnble
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 1 ft. 12 R• Sand Pour
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
20:DRILLING LOG:a'tfach additional sheeis.if,necess'a '"
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc..
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 4 ft. Tan sandy clay
4.Date Well(s)Completed: Well ID#
01/05/2021 MW-32 4 ft. 12 ft. Direct push; no recovery
fr. ft.
5a.Well Location:
Red Apple Market #12 0-0000022799
Facility/Owner Name Facility ID#(if applicable)
3336 US Hwy 13 N, Powellsville, NC 27967
Physical Address,City,and Zip 21.'REi11ARKS
Bertie 6900-78-8498
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
36.22975 N 76.933167 W �QJyO +U7! 01/08/2021
Signature of Certified Well Contractor Date
6.Is(are)the well(s): 21'ermanent or ❑Temporary By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
with I5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONO copy ofthis record has been provided to the well owner.
If this is a repair,fill out/mown well consiniction information and explain the nature of the
repair under#21 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: �,, t, q �,cr6struction details. You may also attach additional pages if necessary.
n, ,
For multiple injection or non-water supply wells ONLY with the sailto oeslrlrtcUdlq ybu can"
submit oneform. ti t+�»°' - SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 12 1124a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths it dii ferem(example-3@200'and 2@I ) ejonst%ction t0 the following:
0.38 \.J1e
10.Static water level below top of casing: -f^ Cis`". r_,(ftf)il Division of Water Resources,Information.Processing Unit,
Ifwater level is above casing,use"+" v 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 3.5 (in.) 24b.For Infection Wells ONLY: in addition to sending the form to the address in
Hand Auger/Direct push 24aabove, also submit a copy of this form within 30 days of completion of well
12.Well construction method: 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