GW1-2021-05275_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: � � � 1,14 VATER;ZON1 S „f :
Justin Radford FROM TO DESCRIPTION
Well Contractor Name JO 5 ft 15 ft• I gray silty sand
3270 A ,toil processlrlg nil ft. ft.'3,, i 15:Ot3TERCASING'for,mulh=cesillN•ells OR°;LINER ifa licatile
NC Well Contractor Certification Number ONtR SeCr-01
FROM TO DIAMETER THICKNESS MATERIAL
Geological Resources, Inc. ft. ft. in.
Company Name lT t11VNERGASING OR`TUB[NG-jeothermalFclii d!,,loo
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 tt. 5 ft. 2" i" SCh 40 PVC
List all applicable well permits(i.e.County,State, Variance,Injection,etc)
ft. ft. in.
3.Well Use(check well use): t417 SCREEN rPa� ems`
Water Supply Well: FROM TO DIAMETER SLOT SIZE 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/Commercial ❑Residential Water Supply(shared) FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑bTi ation 0 ft. 3 tt. Concrete Pour
Non-Water Supply Well:
©Monitoring ❑Recovery 3 rt. 4 11. Bentonite pour
Injection Well:
❑Aquifer Recharge ❑GroundwaterRemediation Ml.9igAND/GRA`(VEL P,AGKj ifap`p1icable fr 4
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 4 ft. 15 ft• ;Sand Pour
t',2VDRILL1NGiff1 aftaeh*a'Raitio"nal s""hee`ts if<nec'"essii €� z
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 0.5 ft. Gravel
04/14/2021 MW-5 0.5 rt. 7 ft. Brown silt
4.Date Well(s)Completed: Well ID#
7 fit. 11 ft. Red brown silty sand
5a.Well Location: 11 ft• 15 fa Gray medium silty sand
Carolina Freightliner-Western Star N/A
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
3890 Jolly Road, Ayden, NC
Physical Address,City,and Zip 21I2ElS9ARKSr� � a �� :
Pitt 63326 Wet at 5'
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) 1J
35.488784 N 77.428711 W r(/ 04/23/21
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary 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: ❑Yes or FIND 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 421 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 saute construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 15 (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@D200'and 2@100') construction to the following:
10.Static water level below top of casing: 5.49 (ft.) 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: 6.25 (in.) 24b. For Infection Wells ONLY: In addition to sending the form to the address in
6 1/4" Solid flight 24aabove, also submit a copy of this form within 30 days of completion of well
12.Well construction method: g 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