GW1-2021-05374_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 �� �"ya� � FROMAia'zoN �,
M TO DESCRIPTION
Well Contractor Name 3 ff• 12 ft• ` Gray medium sand
3270 11�N X � ft. ft.
r
GeologNC Well itractor cal Resation ourcesr Inc�n#crt at'on se don
Unit �I�SO UTER,C QI7YG fO nDIAM DIAMETER B' tICMATERI.AL
g lQNNR On tt. ft. in.
FROM TO
TOIN('.sORTU DIAMETER ,
Company Name 3 _W 1 eo hermat los d loo
THICKNESS MATERIAL
2.Well Construction Permit#: N/A 0 ft, 2 ft. 2 in- SCh 40 1 PVC
List all applicable well permits(i.e.County,State, Variance,Injection,etc)
ft. ft. in.
3.Well Use(check well use): 1? GREEN;
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 2 ft. 12 fL 2 i"' 1 0.010 SCh 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water SuPPIY(single) fa ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 rL 0.5 ft. grout pour
Non-Water Supply Well:
RMonitoring ❑Recovery 0.5 ft. 1 ft. bentonite pour
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 6(19 SA DIGRAV L PA'CsI Ica li bie
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 1 tt. 12 fL #2 Sand pour
❑Aquifer Test ❑Stormwater Drainage tt. fa
❑Experimental Technology ❑Subsidence Control
20:DII liINGf1G(atfaeli addivional stieet"sif ecessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soittrock type,gmin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 0.50 ft. Concrete
4.Date Well(s)Completed: 04/1 3/21 Well ID#M W-20 0.50 ft. 3 ft. Tan medium sand
3 ft. 6 ft. Gray medium sand
59.Well Location: 6 ft. 12 ft. DPT; no recovery
Speedway #8262 n/a ft. ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
10816 NC Highway 55, Grantsboro, NC
Physical Address,City,and Zip 21 RENIART S �� � ;
Pamlico 6541-5310-8000
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) (Q �
35.140436 N 76.841286 W 04/23/21
Signature of Certified Well Contractor Date
6.Is(are)the well(s): 21'ermanent 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 Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes 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 P21 remarks section or on the back ofthis 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 oneform. 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 dierent(example-3@200'and 2@100') construction to the following:
3.05 Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: (ft.)
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 3.5 (in.) 24b. For Infection Wells ONLYc In addition to sending the form to the address in
3.5 DPT 24aabove, 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(gpm) Method of test: 24c.For Water Supply&Injection Wells:
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