GW1-2021-00273_Well Construction - GW1_20210126

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WELL CONSTRUCTION RECORD For Internal Use ONLY: j
This form can be used for single or multiple wells ll
1.Well Contractor Information:
Justin Radford FROM
TER ZONES
f\ TO DESCRIPTION
Well Contractor Name 5 ft. 17 ft. brown-gray silty clay
3270 A ft. ft. I
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINERI if a licabke
FROM TO DIAMETER 'THICKNESS MATERIAL
Geological Resources, Inc. ft. ft. i"•
Company Name >16..INNER CASING OR TUBING 'eothermal closed4066
WM0501419 FROM TO DIAMETER 'THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 2 ft. 2" !" sch 40 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 ft 17 ft 2 i" 0.010 sch 40 PVC
f. f. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water SuPPIY(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18."GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft' 0.5 ft. Concrete Pour
Non-Water Supply Well:
0
©Monitoring ❑Recovery .5 rt. 1 s. bentonite Pour
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRA tEL'TACK if a '1ii'able
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 1 17 ft' (Sand Pour
❑Aquifer Test ❑Stormwater Drainage
ft. rt.
❑Experimental Technology ❑Subsidence Control
20:'DRILL7NG;liOG.attach addifio'nal sheets if necessa y.
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soittmck type,gmin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft' 0.5 ft' Concrete
01/06/2021 MW-14 0.5 ft 10 ft Gray silty clay
4.Date Wells)Completed: Well ID# 10 ft- 17 ft. Brown silty clay
5a.Well Location: R. ft.
RAM #9 0-00-0000026624
Facility/Owner Name Facility ID#(if applicable) ft. ft.
100 West Jackson Street, Rich Square, NC
Physical Address,City,and Zip 21 REMARKS
Northampton .5902-53-6084
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one lot/long is sufficient)
36.274043 N 77.284546 W `Qoy� 01/08/2021
Signature of Certified Well Contractor ! Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A 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 EDNo copy of this 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#21 remarks section or on the back of this 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 �. ,� y Iconstruction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY wish the sameTOJslri'r tion,you can-, z,
submit oneform. �' ec.-•.= SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 17 ^ ( &4a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@100rl co Still tion to the following:
17.05 r, r� :�
i it` Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: ,_.r�,-s'i,.,s." ._ -.�(fr))l� g
lfivater level is above casing,use"+" "" ]t j'j1 r -�"' 1617 Mail Service Center,Raleigh,NC 27699-1617
It.Borehole diameter: 6 (in.) 24b. For Infection Wells ONLY. In addition to sending the form to the address in
11 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 i enter,Raleigh,NC 27699-1636
24c.For Water Supply&Infection Wells:
13a.Yield(gpm) Method of test: 1
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-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013