GW1-2021-07065_Well Construction - GW1_20211129

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Thomas J. Benthall, Jr. 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4508-B 4.49 ft- 9.0 ft- surficial aquifer
ft. fL
NC Well Contractor Certification Number 15.OUTER CASING;for multi-cwed~wells ORLINER if a &cable
Labrador Environmental Consultants, P.C. FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. iu.
Company Name
16.INNER CASING OR TUBING e"othermal closed-loo
2.Well Construction Permit#: NA FROM TO I DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0 fL ft 3 in' 0.154 in. I Sch 40 PVC
3.Well Use(check well use): f, ft. in.
Water Supply Well: 17.SCREEN, r.'i
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 3 0 fL 9.0 ft. 2 in. 0.010 in. 0.154 in. Sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. 3.0 ft. rm
❑Industrial/Commercial ❑Residential Water Supply(shared) I&GROUT G
01nigation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 1.0 ft concrete grout gravity flow,<25 lb
InMonitoring ❑Recovery 1.0 ft. 2.0 fL bentonite chips gravity flow,<5 lb
Injection Well: fL ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK,rf a"`-li¢'able
❑Aquifer Storage and Recovery ❑Salmlty Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 2.0 ft• 9.0 fL #2 washed filter sand gravity flow
❑Experimental Technology El Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG°attach additional sheets if necessa '
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 RemarksLJ
FROM I TO DESCRIPTION color,hardness soillrock type,grain sae eta)
0 ft 7.0 fl brown silty fine sand
4.Date Well(s)Completed: 10/26/2021 Well ID# MWA 4R 7.0 ft. 9.0 ft. grayish tan silty fine to medium sand
5a.Well Location: ft. ft.
Abu Amin, Inc. UST Section Incident No.38040 ft. ft.
Facility/Owner Name Facility ID#(if applicable) fL ft.
540 NC Highway 55 East, Bridgeton, NC 28519 ft. &
Physical Address,City,and Zip ft. fL
Craven 2-036-217 21.REMARKS "'
County Parcel Identification No.(PIN) NOV 2
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: r�
(if well field,one IatA sufficient)
ong is sucient) 22.Certifica' DWR SECTION
35.121687 N -77.005501 W INFORM.-dtlON PROCFSSINY42021
6.Is(are)the well(s): 19Permanent or ❑Temporary Signature ofCe a 11 Con ctor Date
By signing thi form,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
_repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Ovee in Remarks Box).You may also attach additional pages if necessary.
drilled:N/A 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 9.00 (ft)
For multiple wells list all depths if different(example-3@200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
4.49 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwater level is above casing,use"+"
f Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
I I.Borehole diameter: 3.625 (in) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Hared Auger
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gP m) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1 61 1
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018

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