GW1-2021-05277_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 w 14.WATER10NE5
FROM TO DESCRIPTION
Well Contractor Name a... 5 ft. 15 ft• Gray silty sand
3270 A X 2021 ft. ft.
NC Well Contractor Certification Number C VYtlt 15.'OIJTER CASING,fo�mulDIAMEh cased
FROM wells'ORINER ifa`licatile rt �
p fQGf; SiBf� TO TER CK THINESS MATERIAL
Geological Resources, Inc. `njoltration ;on ft. ft. in.
Company Name 1J6.J11"ER CASING"OR TUBING(eothemalact&e—d
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft' 5 tt. 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): 17SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5 ft' 15 ft' 2 in. 0.010 sch 40 PVC
f. t. in.
[]Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 8:'GROUT_
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Iri ation 0 ft. 3 ft- Concrete Pour
Non-Water Supply Well: 3 ft. 4 rL Bentonite pour
17Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation ; 19.SAND/GRAVEL"PACK ;f.,a'liable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHODft. ft.
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 4 ft. 15 fL Sand Pour
&20.�DRILLINGW0G attach a�diiional stieets,if necessa" ;
❑Geothermal(Closed Loop) []Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Cther(explain under#21 Remarks) 0 ft. 5 ft. Light brown fine silty sand
04/14/2021 MW-3 5 ff 15 ft• Gray fine silty sand
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location:
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 , ,, -., ,F
2l.RE111ARKS". ' _<� r H '.
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) /�L
35.488784 N 77.428711 W '(/ 04/23/21
Signature of Certified Well Contractor, Date
6.Is(arc)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certify 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 existing well: ❑Yes or ONo 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 ofthe
repair under 921 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: 15 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi/ferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing:4.94 (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: 9 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 ihealth department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013