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GW1-2021-00503_Well Construction - GW1_20211222
WELL CONSTRUCTION RECORD For Internal Use ONLY: This form can be used for single or multiple wells 1.Well Contractor Information: J14,wATERZONES- Justin Radford FROM TO DES CRD'TION Well Contractor Name IL ft. 3270 A % ft. NC Well Contractor Certification Number 15.OUTER CASING form ulti-i:it'sed we1b ORLINER if a"`llcable FROM TO DIAMETER TIlCKNESS MATERIAL. Geological Resources, Inc. IL ft in. Company Name 16.=INNER CASING OR,TUBING e'othermalclosed-loo WM-06O1186 FROM TO DIAMETER THICKNESS MATERIAL 2.Well Construction Permit#: 0 ft. 2 fa 2" in. sch 40 PVC List all applicable well permits(i.e.County,State,Variance,Injection,etc.) fL ft. iR. 3.Well Use(check well use): 17.SCREEN Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL ❑Agricultural ❑Municipal/Public 2 fG 12 it' 2 in. 0.010 sch 40 PVC ❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fL fL ❑Industrial/Commercial ❑Residential Water Supply(shared) 18.,GROUT „. FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT ❑h7i ation 0 fa 0 5 fa Grout Pour Non-Water Supply Well: ©Monitoring ❑Recovery 0.5 fL 1 fc Bentonite Pour Injection Well: ft. ft. ❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVELPACK{if i licible ❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATFRL&L 11 EMPLACEMENT METHOD ❑Aquifer Test ❑Stormwater Drainage 1 1" 12 ft. Sand Pour ft. IL ❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG_attack iidditioaa"I:iheets if n"ecess`a ❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soiurock in size,ete) ❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft ft. Brown sand 4.Date Well(s)Completed: Well ID# 11/08/2021 MW-2 5 ft- 12 ft. Brown/tan coarse sand ft. ft 5a.Well Location: ft. ft. EJ Pope Hwy 87 Spill ft. ft ' ti Facility/Owner Name Facility m#(if applicable) fL f4 NC Highway 87, Cumberland, NC DEC IL ft Physical Address,City,and Zip 21 REMARKS Cumberland 0443-66-2439 "%Wik, :., �r•�,tnr County Parcel Identification No.(PIN) 5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: (if well field,one Iattlong is sufficient) 34.949262 N 78.845897 W Signature,fCertifiedWell ntractor 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 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a 7.Is this a repair to an existing well: ❑Yes or EJNo copy ofthis record has been provided to the well owner. Ifthis is a repair,fill out known well construction information and explain the nature ofthe repair under#11 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: 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: 12 (ft.) 24a. For All Wells: Submit this'.form within 30 days of completion of well For multiple wells list all depths ifdifferent(example-3@200'and 2@100) construction to the following: 10.Static water level below top of casing: 7.30 (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 (in.) 24b.For Infection Wells ONLY: IIn addition to sending the form to the address in auger Solid flight 24aabove, also submit a copy of this form within 30 days of completion of well 12.Well construction method: 9 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. I Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013 k