GW1-2021-05763_Well Construction - GW1_20211015

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Justin Radford 14.WATER ZONEs
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
3270 A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for
FROM TO moltiad wells ORINs cable
DMER MATERIAL
Geological Resources, Inc. ft. ft. I in.
Company Name 16.INNER CASING OR TUBING `eothermal closed-loop)`
FROM TO DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft' 5 ft- 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 SITE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5 ft' 15 ft' 2 in. 0.010 sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft• ft- in.
❑Industrial/Commereial ❑Residential Water Supply(shared) 18 GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 3 f• Grout
Non-Water Supply Well:
ft. ft.
©Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK" applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
3 ft• 4 ft Bentonite
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 4 ft 15 f• Sand
20.DRILLING LOG attach additional`iiheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,wutrock etc.
❑Geothermal (Heating/Cooling Return ❑Other(explain under#21 Remarks 0 tt 15 ft DPT;no recovery
ft' ft'
4.Date Well 07/15/2021 s)Completed: Well ID#MW-1
ft. ft.
5a.Well Location:
3750 South Memorial Drive n/a
Facility/Owner Name Facility ID#(if applicable)
3750 South Memorial Drive, Greenville, NC
Physical Address,City,and Zip
21.REMARKS r
Pitt 16368
b'J
County Panel Identification No.(PEN)
51b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
35.56172 N 77.40578 W 08/25/2021
Signature of Certified Well Contractor Date
6.Is(are)the well(s): 2Permanent or ❑Temporary By signing this form,I hereby cernfy that the wells)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 eidsting well: ❑Yes or 0No copy of this record has been provided to the well owner.
If this is a repair,fill out!mown well construction information and erp/ain 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 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: 15 (ft.) 24a. For All Wells: Submit this fora 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: 6.89 (fL) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 3.25 (in.) 24b. For Iniection Wells ONLY: In addition to sending the fort to the address in
Direct nU$h 24aabove, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Direct 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&Injection 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.
i
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013