GW1-2021-02380_Well Construction - GW1_20210601

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple;wells
1.Well Contractor Information: ��� �
Justin Radford PE 14:•WATERZONES
FROM TO DESCRUMON
Well Contractor Name ,U N 't021 fL %
3270 A Unit .IS.OUTERCASIxG formniti-easy
NC Well Contractor Certification Number 'n�QI ,3t10I1 pfOC@SS1tlg ed wells OR LINER a`"lieable : ..
p����$eCCOfI FROM TO DIAMETER I THICKNESS MATERIAL,
Geological Resources, Inc. ft. ft in.
Company Name 16.ENNER CASING OR TUBING'"eothermai closed-to'o`
WM0701244 FROM TO DIAMETER THICKNESS MATERLAL
2.Well Construction Permit#: 0 ft' 2 % 2 in. 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 SLZE I THICKNESS I MEITERIAL
❑Agricultural ❑Municipalftblic 2 ft. 12 e. 2 111' 0.010 sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared)
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 it- 0.5 fL Grout
Non-Water Supply Well:
OMonitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL°PACK tf a" licable "-�
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD0 5 ft' 1 & l3entOnite
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 1 ft 12 fL
Sand
A0.DRILLING LOG Attach additional shiets,if accesse ,
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION color,hardness,soilfrock type,grain size,etc
❑Geothermal eating/Cooting Return ❑Other(explain under#21 Remarks) 1 0 ft- 12 ft DPT;no recovery
4.Date Well 04/28/21 MW-3Rs)Completed: Well ID# tt ft
5a.Well Location: ft. fL
Sligo Citgo 0-0000033554 ft. %
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
2152 Caratoke Highway, Moyock, NC ft. fL
Physical Address,City,and Zip 21 REMARKS
Currituck 003-200000-620000
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)
36.4527 N 76.077744 W 05/19/21
Signature of Certified Well Contractor Date
6.Is(are)the well(s): 2Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or EINo 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
S.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 th.is form within 30 days of completion of well
For multiple wells list all depths if di fferent(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: 2.29 (fL) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 3.5 (in.) 24b.For Injection Wells ONLY: In addition to sending the form to the address in
Direct nU$i1 24aabove, also submit a copy of this form within 30 days of completion of well
12.Well construction method: P 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
24c.For Water Supply&Injectil ni Wells:
13a.Yield(gpm) Method of test: 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 WaterIResources Revised August 2013