GW1-2021-02694_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 qa �l '44.3y'?TER�ZONEs
�' (� ,{y,-.' FROM T2 ,.'DESCRIPTION
Well Contractor Name
3270 �vV 20tt� rt. rt.
NC Well Contractor Certification Number UB�I aa5 OI7TER GASING'fdr- ca'se`d:;�sells.,OR INER,iP:a'licatile " `
Geological Resources Inc. In4crr�^�at:on pro
FR01I TO DIAMETER THICKNESS MATERIAL
®�,r R seCfOn ft. ft. in.
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Company Name 16.�INN_ER CASING.OR7TI- 1NG'ee61hermal closedtlii v `"
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: NSA 0 ft. 4 ft. 2 in. sch 40 PVC
List all applicable well permits(i.e.County,State,Variance,Injection,etc)
ft. to in.
3.Well Use(check well use): M, 7:,�SGRI
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 4 tt. 9 ft. 2 i" 0.010 sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) in.
❑Industrial/Commercial ❑Residential Water Supply(shared) MV
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 2 ft rout our
Non-Water Supply Well: 9 p
2 rt. 3 rL bentonite pour
EMonitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation i9.I9AND/GRAVELkPACKf if`'p'#Iicable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 3 rt. 9 ft. #2 sand pour
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control s T(S-�
20:1DRILI:INGIIOGs attaEch adilii`ional shee
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rink type,gmin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 1 ft. Brown fine sand
4.Date Well(s)Completed: 04/1 3/21 Well ID#Mw-2 1 ft. 6 rt• Gray clayey sand
6 ft. 9 ft. DPT; no recovery
5a.Well Location:
Speedway #8212 0-025295 tt.
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
1305 West Blvd, Williamston, NC rt. rL
Physical Address,City,and Zip k21:-RENIARKS'
Martin 0502104 Refusal at 9'
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one Iat/long is sufficient) :
35.840899 N 77.07153 `,1, a 04/23/21
Signature of Certified Well Contractor Date
6.Is(are)the well(s): 2Permanent or ❑Temporary By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Consiniction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONO copy ofthis record has been provided to the well owner.
/f 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: 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: 9 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells/is/all depths if dfferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 3'82 (ft.) 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 Infection Wells ONLY: In addition to sending the form to the address in
35 DPT 24a above, also submit a 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 m Method of test: 24c.For Water Supply&Injection Wells:
(gp ) 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-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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