GW1-2021-05278_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:
q*4 ' 14.WATER ZONES:
. g '
Justin Radford ,� FROM TO DESCRIPTION „y
Well Contractor Name
3270 it. ft.
NC Well Contractor Certification Number CeSSlflO Ur<� J&5,OUTER CASING for mu1H-cased HI
�ri wells OR LINER if a hcable
Geololom"3"1011 pro FROM To DIAMETER TCKNEs9 MATERIAL
ical Resources, Inc. «
g D�i� SecC,on ft ft : in.
Company Name 16i INNER CASING OR TUBING 'eiithermal closedgoo = ,
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: N/A 0 ft 6 fL 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): 17:SCREEN, __s
Water Supply Well: FROM I TO I DIAMETER I SLOT SIZE THECKNMS I MATERIAL
❑Agricultural ❑Municipal/Public 6 It- 16 ft 2 "' 0.010 sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 19.-GROUT_
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
[]Irrigation 0 ft. 2 ft. grout pour
Non-Water Supply Well:
2 ft 4 rt bentonite pour
BMonitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVELTACK ,a licatile '
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 4 ft. 16 ft. #2 Sand pouf
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20 DRILLING LOG ittachTadditioual iheets if iiecessa"
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,h■rdnes soil/rock type,pain etc
❑Geothermal eating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 6 ft. Air knife;no recovery
4.Date Wel(s)Completed: 05/1 1/2 1 Well ID#MW-1 6 ft. 16 ft Orange interbedded sand and clay
ft. it.
5a.Well Location: ft. fL
Speedway #8283 n/a ft. ft.
Facility/Owner Name Facility ID#(if applicable)
fL ft.
4985 Old Tar Road, Winterville, NC & %
Physical Address,City,and Zip 421.41EMARKS ,
Pitt _ 54699
County Parcel Identification No.(PEN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.525383 N 77.384433 W 1244
Signattge of Certified WA Contract Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with I5A 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 E]No 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#21 remarks section or on the back of this farm. 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: 16 (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@200'and 2@1001 construction to the following:
10.Static water level below top of casing: a.S'D (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. (in.) 24b.For Injection Wells ONLY: In addition to sending the form to the address in
hand au er 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
i
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