GW1-2021-00606_Well Construction - GW1_20210205

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Ronald F. Barron 14.wATERZONEs
FROM TO DESCRIPTION
Well Contractor Name k
2 ft. ft.
091-A
ft. ft.
NC Well Contractor Certification Number l5 OUTER.CASING f6riiiiulh cased iwells 0j1.INER'ifra
Pidmont Industrial Services FROM TO DIAMETER THICKNESS MATERIAL
+3 ft- 15 'It- 1 2" j in. Sch 40 1 PVC
Company Name
Neoth16:INNER'GASING0RTUBING "
ermahclosedloo
2.Well Construction Permit#: " -/A FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
I 17sSCREEN d:
Water Su =-
pp y Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public 5 ft. 20 fL 2 i"- .010 Sch 40 PVC
Geothermal(Heating/Cooling Supply) DI Residential Water Supply(single) ft. ft. in.
Industrial/Commercial DI Residential Water Supply(shared)
I Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 1.5 ft. 3.5 ft- 3/8 Bent'.Chips Trimie
Monitoring DRecovery 0 ft 1.5 ft. Concrete Mix Poured
Injection Well:
ft. ft.
Aquifer Recharge DGroundwater Remediation
:19iSAND/GRAVEL''PACK tf.a` licable " ` "
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
Aquifer Test DStormwater Drainage 3.5 ft 20 rt• #3 Filter Sand Trimie
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) D)Tracer 20.:DRII:LING:LOG attiicti additioualaheets if iiecessa
Geothermal(Heating/Cooling Return) X Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness,soillrock type,grain sim,etc.
0 ft 5 ft. tan fine silty sand
4.Date Well(s)Completed: 1-28-2021 well ID#GM-25 5 ft 15 ft' grey §I illy clayey sand
5a.Well Location: 15 1L 20 ft' grey to white course to fine silty clayey sand
Sampson Co. Disposal N/A ft. ft. BT 20'
Facility/Owner Name Facility ID#(if applicable) ft. ft.
7434 Roseboro Hwy, Roseboro, 28382 ft. ft.
Physical Address,City,and Zip fL ft.
Sampson N/A z1aREMARKS :.i _._ _ -
County Parcel Identification No.(PIN) Methane Gas monitoring well. Well set Wabove ground
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: casing, concrete pad, lock, tag, ID#.
(if well field,one lat/long is sufficient) 22.Certification:
34 58.7280' N 78 28.1500' W 2-2-2021
6.Is(are)the well(s)�Ix Permanent or DTemporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Di Yes or X®No with I5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under 921 remarks section or on the back of this form.
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 site details or well
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:N/A SUBMITTAL INSTRUCTIONS
i
9.Total well depth below land surface: 20 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 14'+-
(ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"T" /v 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 10 (in.) For Infection Wells: In addition to sending the form to the address in 24a
Au er '' /I above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: g "'!:c, ,n)� construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) i J7
o pt0 Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: @ctiQn�04n9 j' 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c. For Water Supply&Infection Wells: In addition to sending the form to
the address(es) above, also submit°one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to Ithe county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016