GW1-2021-00571_Well Construction - GW1_20211222

i
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Sam Bowers 14.NVATE1tZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
3220 A ft. ft.
NC Well Contractor Certification Number 15.'OUTER CASING fot,muld-cased.welli OR LINER'(if.e""Tics _
FROM TO DIAMETER I THICKNESS I MATERIAL
Geological Resources, Inc. ft ft. I In.
Company Name 16.INN ER CASING-'OR TUBING eethermal cl6iM400"
WM0601182 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 2 ft. 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): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 2 fa 12 It. 2 i°' 0.010 sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.'GROUT, it.: �,_ _ ,'awl
FROM TO MATERIAL EMPLACEMENT METHOD&
❑hTi ation 0 ft' 0.5 ft. Grout Pour
Non-Water Supply Well:
OMonitoring ❑Recovery
0.5 ft- 1.5 ft. Bentonite Pour
Injection Well: ft. ft.
❑Aquifer Recharge El Groundwater Remediation 19.SAND/GRAVEL PACK'If apolleall _
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
1.5 fa 12 fa Sand
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG.attfik additional sheetsaf necessas '
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,sodfrock in a etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 0.5 ft Asphalt
4.Date Well(s)Completed: Well ID#
10/27/2021 MW-4 0.5 ft. 3 fi. Dark brown sandy clay
3 ft- 7 ft. Tan medium sand
5a.Well Location:
DECO (J & J Texaco) 0-00-0000019342 7 rt. s ft. Tan medium sand
9 fc• 11 ft. Gray/ i=sand
Facility/Owner Name Facility ID#(if applicable) 11 ft 12 ft Tan SI m di m
610 Union Chapel Road, Pembroke, NC ft. % DE
Physical Address,City,and Zip
21ItEMARK5 .' - �'-
Robeson 9344-4037-4400
County Parcel Identification No.(PIN) �.�p p;���+
IRfA r��VliCs7S I'
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification.-
(if well field,one lat/long is sufficient)
34.686412 N 79.185758 W 10/29/21
Signature of Certified Well Contractor Date
6.Is(are)the well(s): 2Permanent or ❑Temporary By signing this form,1 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 ONo copy of this record has been provided to'the well owner.
Ifthis is a repair,fill out known well construction information and explain the nature of the
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: 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 if dierent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 6.69 (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: In addition to sending the form to the address in
Solid stem au 24aabove, also submit a copy of this form within 30 days of completion of well
er
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 health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water`esources Revised August 2013