GW1-2021-03353_Well Construction - GW1_20210603

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Justin Radford F 4.WATER ZONES FROM TO DESCRIPTION
Well Contractor Name ft.
3270 A -+ftt ft.
NC Well Contractor Certification Number -15.OUTER CASING for c ap able)
f!1t, AsId�Wells)
FROM TODIAMETER ?am ITCMATERIAL
Geological Resources, Inc. ft. ft. 1 in.
Company Name �,46.-INNER CASING ORTUBING'i6iitfiermal closed-too')
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 2 SCh 49_L PVC
List all applicable well permits(i.e.County,State, Variance,Injection,etc)
ft. in.
3.Well Use(check well use): ,47.SCREM!--,
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural OMunicipal/Public 2 ft. 12 R. 2 in,. 0.010 sch 40 PVC
ElGeothermal(Heating/Cooling Supply) oResidential Water Supply(single)
,, ,`,"
0 Industrial/Commercial oResidential Water Supply(shared) 18.GROUT., N
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
DIrrigation 0ft. 0.5 ft- Concrete Pour
Non-Water Supply Well: 0.5 ft- 1.0 ft- Bentorlite Pour
[aMonitoring 0 Recovery
Injection Well:
0Aquifer Recharge OGroundwater Remediation ,,,19.SANDIG LPACK(ifapplivable)
FROM TO MATERIAL EMPLACEMENT METHOD
E]Aquifer Storage and Recovery DSalinity Barrier
0Aquifer Test OStormwater Drainage 1 15 Sand Pour
oExperimental Technology OSubsidence Control 20.DRILLING,LOG(attach additional sheet§ifnecessiiy)
D Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
E]Gcothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) 0 ft 0.50 tt Concrete
4.Date Well(s)Completed: 02/01/2021 Well ID#MW-1 0.50 3 Black fine sand
3 ft. 6 ft. Gray fine sand
5a.Well Location: 6 fr. 112 ft. DPT; no recovery
Speedway #8220 0-000032450
Facility/Owner Name Facility ID#(if applicable)
138 Third Street, Ayden, NC
Physical Address,City,and Zip 21.REMARKS
Pitt 40252
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)
35.474769 N77.433686 W 02/17/2021
Signature of Certified Well Contractor' Date
6.Is(are)the well(s): [OPermanent or OTemporary 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: DYes or FIND copy ofthis 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 921 remarks-section or on the back of this form. 23.Site diagram or additional well details:
1 You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 12 (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: 3.59 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"-" 1617 Mail Service(enter,Raleigh,NC 27699-1617
11.Borehole diameter: 3.5 24b. For Infection Wells ONLY'- In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Direct Push 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 r Wells
Also submit one copy of this to I rm 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 WaterResourccs Revised August 2013