GW1-2202-00593_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:
14.WATER ZONES
Sam Bowers FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
3220-A ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells OR LINER`if a "dcable
FROM TO DIAMETER TffiCKNESS MATERIAL
Geological Resources, Inc. rt,
ft. in.
Company Name 16•INNER CASING OR TUBING "eothermal:closed-loo"
FROM TO I DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 'A'V/A 0 ft' 5 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 is
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5 ft- 20 ft. 2 in. 0.010 soh 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
❑hri ation 0 ft. 2 ft. grout pour
Non-Water Supply Well:
2 ft 4 ft bentonite pour
2Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier
FROM TO It MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 4 It- 20 #2 sand pour
ft. ft.
❑Experimental Technology. ❑Subsidence Control
20 DRILLING LOG.attach additional sheets ifliecessa `:.
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain size etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 0.25 fL Asphalt
4.Date Well(s)Completed: 09/20/21 Well ID#MW-2 0.25 fL 4 ft. Light brown to dark brown silt
4 ft• 13 ft• brown to light bro ..
5a.Well Location: 13 ft- 20 fi' tan silt "
Nics Pic Kwik #7 00-0-0000026088 ft OL U 2 2 Z
021
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
13700 Andrew Jackson Highway, Laurinburg, NC ft ft. t
Physical Address,City,and Zip ltoF
21.REMARKS
Scotland 010025 01018
County Parcel Identification No.(PIN)
(ifwell field,one at/lLatitude and oogissuffici nde in degrees/minutes/seconds or decimal degrees: 22.Certification: ^
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(s)was(were)constructed in accordance
with 1 SA 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 E]No copy ofthis 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@100) construction to the following:
10.Static water level below top of casing: 12.42 (fL) 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 Iniection Wells ONLY: In addition to sending the form to the address in
au er Err Solid Fli ht 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
i
13a.Yield(gpm) Method of test:
24c.For Water Supply&Injection Wells:Also submit one copy of this form i 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