GW1-2202-00592_Well Construction - GW1_20221222

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Sam Bowers 1F4R.WMATER Z ONES DESCRIPTION
Well Contractor Name ft. ft. I
3220-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING'for muld-cased wells OR^LINER;if a' licable s ,
FROM TO DIAMETER TRICKNESS MATERIAL
Geological Resources, Inc. ft. ft. in.
Company Name 16.-INNER CASING OR TUBING 'eothermat;elosed-loo -
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: NSA 0 ft' 5 ft 2 in. soh 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 u
Water Supply Well: FROM TO DIAMETER SLOT SUM THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5 ft' 20 ft. 2 1n. 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
❑lrri ation 0 ft. 2 ft grout pour
Non-Water Supply Well:
OMonitoring ❑Recovery 2 ft. 4 It. bentonite pour
Injection Well: ft. fa
❑Aquifer Recharge ❑Groundwater Remediation 19.3AND/GRAVEL PACK if applicable)` .
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
4 ft. 20 ft. #2 sand pour
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additiofial aheetsYi•necessa `
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,'oil/rock type,grain size,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 1 fQ Dark brown silty sand
4.Date Well(s)Completed:
09/21/21Well ID#MW-4 1 ft. 3 ft. Brown to gray brown silty sand
3 ft. 4 ft. Brown to red silty clay
5a.Well Location: 4 It' 12 ft. Brown silt
Nics Pic Kwik #7 00-0-0000026088 12 IL 20 ft. Tan silty clay
Facility/Owner Name Facility lD#(if applicable) ft. ft.
13700 Andrew Jackson Highway, Laurinburg, NC ft ft
Physical Address,City,and Zip 21.REMARKS
Scotland 010025 01018
County Parcel Identification No.(PIN) F
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
34.777775 N 79.488986 W 10/18/21
Signature of Certified Well Contractor Date
6.Is(are)the well(s): 21'ermanent or ❑Temporary By signing this form,I hereby certify that the well(q)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ®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 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: 20 (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@I00) construction to the following:
10.Static water level below top of casing: 13.40 (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
Ell Solid Flight 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 liealth department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water,Resources Revised August 2013