GW1-2021-00572_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:
14.WATER ZONES
Sam Bowers FROM TO DESCRIPTION
Well Contractor Name ft. fL
3220 A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING formalti-cased[we OR LINER' s-Ileable .,
FROM TO DIAMETER THICKNESS MATERIAL
Geological Resources, Inc. ft ft. in.
Company Name /� 16.INNER CASING OR-TUBING ebthermal closed-1660
0601182 FROM TO DIAMETER THICKNESS MATERIAL
WM
2.Well Construction Permit#: 6 0 & 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.sSCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 2 ft- 12 fi. 2 "' 1 0.010 sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 0.5 ft- Grout I Pour
Non-Water Supply Well:
0.5 ft 1.5 ft Bentonite Pour
@Monitoring ❑Recovery
Injection Well: h• ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if s i cable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 1.5 ft' 12 ft. Sand
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional;aheets if nece's`sa'
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardnes soilfrock bTe,grain s' etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft •5 ft. Asphalt
4.Date Well(s)Completed: 10/27/2021 Well ID#M W-3 0.5 ft. 5 ft. Dark gray medium sand
5 ft. 7 ft. Gray medium sand
5a.Well Location: 7 ft 11 ft. Gray/tan medium sand
JECO (J & J Texaco) 0-00-0000019342
11 fQ 12 ft. Re dium sand
Facility/Owner Name Facility ID#(if applicable) ft. ft
610 Union Chapel Road, Pembroke, NC
ft. ft. D
Physical Address,City,and Zip E1.REMARKS
Robeson 9344-4037-4400
County Parcel Identification No.(PIN) itC:s .rsr��t,1r
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one latllong is sufficient)
L '
34.686412 N 79.185758 W 10/29/21
Signature of Certified Well Contractor 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 02C.0100 or I5A NCAC 01C.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 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: 12 (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@100) construction to the following:
10.Static water level below top of casing: 7.01 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater 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 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
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