GW1-2021-00607_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.WATER ZONES
. ..
FROM TO DESCRIPTION
Well Contractor Name ft. ft. G
2091-A
ft ft.
NC Well Contractor Certification Number 15r OUTER CASING(for cmalh ca'sedt`wells "ORS3INER`ifE'a livable ,
Pidmont Industrial Services FROM TO DIAMETER THICKNESS MATERIAL
+3 ft 5 ft- 2" i" Sch 40 PVC
Company Name
NUBIN/� 16.INNEWCASINGiOR T
G "eother`itial'closed loo'
2.Well Construction Permit#• ' "/- - 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.
Water Supply Well: 17c'SGREEN. - 11
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ®Municipal/Public 5 ft. 20 ft' 2 in. .010 Sch 40 PVC
Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ft. ft. in.
Industrial/Commercial ®Residential Water Supply(shared) IS)'GROUT f . ..
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 OGroundwater Remediation
19.SAND/GRAVEL:PACR'if a"livable ?.
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage 3.5 ft 20 ft. #3 Filter Sand ITrimie
-Experimental Technology Subsidence Control ft ft.
!Geothermal(Closed Loop) OTracer 20:;OBIT LING lOG attacti`iidditioual sheets if:'i ecessa
Geothermal(Heating/Cooling Return) MOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,gmin size,etc.
0 ft 5 fl. brown tan fine silty sand
4.Date Well(s)Completed: 1-29-2021 well ID#GM-26 5 ft 10 1" tan silty clayey sand
5a.Well Location: 10 fL 15 ft* wet grey clayey sand
Sampson Co. Disposal N/A 15 fL 20 ft. wet grey silty clayey sand
Facility/Owner Name Facility ID#(if applicable) ft. It. BT 20'
7434 Roseboro Hwy, Roseboro, 28382 ft ft.
Physical Address,City,and Zip ft. ft.
Sampson N/A 21:iREMARKS a
County Parcel Identification No.(PIN) Methane Gas monitoring Well. Well set w/above ground
casing, concrete pad, lock, tag, ID#.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
34 58.6280' N 78 28.0090' W
� � /4se--- 2-2-2021
6.Is(are)the well(s)oPermanent or Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or JDNo with 15A 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#21 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:N/A SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 201 24a. For All Wells: Submit this;form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3 a,200'and ll100') {/`� k /�,nstruction to the following:
10.Static water level below top of casing: 14i+'. /' (ft.)(JV Division of Water Resources,Information Processing Unit,
If water level is above casing,use `/OJ P , 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 10 m. 0 r
( ) wRS°cesS;n 24b.For Infection Wells: In addition to sending the form to the address in 24a
Auger eCI'%O/� 9 41/1above,also submit one 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&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 pthe 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