GW1-2021-00269_Well Construction - GW1_20210126

WELL CONSTRUCTION RECORD I,,r Internal I!,,ON]v'
'Fh„rune all be land 1'o.sinIII,ur nadtiple ,ea,,
1.Well('.cntractor Information:
Justin Radford 14.WATER ZONES
FRONT 't0 Df:SCR IPTION
'Hell C„mraclor None 15 °' 20 ft- Brown-tan coarse clayey sand
3270 A ft. I ft.
NC w ell Contractor C'eniticaunn Nmnber 15.Of TER CASING(forwells ORLINER i[a ieabk
FRONT 10 DI{11 ETER llll('RNfSS NI ATERI{I.
Geological Resources, Inc. rt. ft. "•
Congranc Name 16.INNER CASING OR TUBING eotbermel closed-loo
FROM 10 DUNIf:T1:R 1'lln KN Ks" NIAT'ERIAI.
2.Well Construction Permit#: 0 ft• 10 ft' 2" t" sch 40 PVC
/nl allapphalhlr urll purvnu.a Ovnn yell l'.nuan.u./nrc.f1„n.u..
ft. ft. in.
3.N%ell Ise(check well use): 17.SCREEN
Water Supply W'CIIo FROM '10 DI:NMf:Tf:R SLUTS("l f: TIII('R\F.55 p1A TRIAL
C:\ericultural ❑MunicipalPubbc 10 ft' 20 ff 2 '"' 0.010 SCh 40 PVC
-Gcothemtal(IleatinJCooling Supple l [-]Residential Abater Supph'(sinele D. n, in.
C Industnal.iComnlercial ❑Residential AAater Supph'(shared) 18.GROUT
FROM 10 MATERIAL EMPLACE%1V\FMETH0D&_AM0l'NT
G lrrneation 0 h' 6 D• Concrete Pour
Non-Water Supply Well:
RNhoutorine ❑Recovcn 6 ft. 8 ft- Bentonite Pour
Injection NN ell: ft. ft.
❑Aquifer Recharge ❑Groundwater Rentct iation 19.SAND/GRAVELPACK t im able
FROM TO MATERIAL EMPL{('ENIF.NT wET110n
❑:Aquifer Storage and RecoNen ❑Salinity Barrier
8 ft. 20 ft- Sand Pour
❑Aquifer lest ❑Slormwater Drainage
ft. ft.
--Experimental Technolog, ❑Subsidence Control
20.DRILLING LOG bittach additional sheets if necessa
=Geodemtal(C'losed Loopl ❑Iracer FROM to D ES('RIPt ION It.lor.bardnessnoilha k 11e,lol..1w.elcl
C Geothermal(Heating/Conlin-,Return) ❑Other(explain tinder#21 Remarks) 0 ft' 0.5 ft. Concrete
4.Date\Yell(s)Completed: 01/04/2021 Weil ID#MW-4 0.5 ft- 4 ft. Light brown medium sand and clay
4 °. 6 ft' Light brown and red clay and med clay sand
5a.Well Location: 6 D' 9 D' Light red clay
EP Mart 16 0-0000036065 9 ft- 17 ft. Brown clay
facihh O„ner Name Llc htc ID-(it applicable)
1800 Benvenue Road, Rocky Mounty, NC 17-ft.
20 fL Brown course to med sand
Phcsicel Address.Cm.and 7ip 21.REb1ARKS
Edgecombe 3851-0915-6185
Count, Parcel Item,fi,aw,riNu (III NI
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 11 (certification:
(it(,ell lidd,one Inn/long is slium,m I
35.984253 , 77.812519 0/u'! `V 01/08/2021
Slenaune ofC,"ified Nell Contractor Dare
6.Is(are)the well(s): laPermanent or El emporan fn •1,rnrge rho l,1rn1. i hero, .calm Chan nm utllnf ,.,.. 1n oe..,n,.l.uo,�l n1 ao<,,.',h.11,.
u 111 151.A(':I('"I( Will ar 1i.l Ar-.-II-"If' n'uo 4,11(-,,n.Ir"nvm A,mderd.and IImI a
7.Is this a repair to an existing well: ❑Yes or BNo alpr of ft......ru'd it....heal pr.n ided L1Om bell onvh-r.
litho I,,,,poll',fill nun knmo,yell, ...onen...nrnmlien and ,/,I If...nails.ul the
.rpa11'..... N 1r...... .en....„..e1 fill h,lrkollho/..'... 23.Site diagram or additional well details:
You nia, use the back of this page to provide additional tn11 site details or well
8.Number of wells constructed: 1 r, qq�nonItuldion details. You min also attach additional paces if necessan_
1111 1hll qam 111r.r,1n-u arrr.urph ,,W,Wort I,ah rh,±ante oont�rrt n.�flAl art
St'B,NII'FI'.-AL INS7I C PIONS
9.Total well depth below land surface. 20 _(ft.) 24a. For ..AIt Wells: Submit this farm within 30 da,s of completion of well
Fan myluph,l"ll,Ica alfaplh.1/daf,,, l/enunple-3a''(I1)'1m 12,1001 construction to the follcNln^-
10.Static water le,el below top of casing: 1 1 .15 (ft.) Division of W-ater Resources.Information Processing I nit,
It wllerl.Id 11 ab„re n11111p.111. 1617 Mail Service('enter.Raleigh.NC 27699-1617
11.Borehole diameter: 6 (i n.) 24h. For Infection Wells ONLY: In addition to sending the form to the address in
6" Steed Flight Au 24aahme, ASO submit It copy of this font within 30 days of completion of well
12.Well construction method: g Auger construction to the following
,,, auecr_rnaq.cI,hlc.direct push.ctcl
Dicisi(in of Water Resources,l ndergrnund Injection Control Program.
FOR\YA"PER SL PPLY NYEL1 S ONIA: 1636)tail Service Center.Raleigh.NC 27699-1636
13a.field(gpm)__ Method of test: 24c. For Water Supple&Injection Wells:
Also submit one copy of this form within 30 daps of completion of
13b.Disinfection t)pe: Amount: well construction to the countx health department of the count,where
con,nucted.
Form Gw'-I Nonh Carolina Dcpanmcnt o(Encimnlncnl and Natural Rcsourcev Di.rsu..I of'All,,I(cwurces Re.iced August-111I3