GW1-2021-00599_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:
Justin Radford AVATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
3270 A
NC Well Contractor Certification Number 15 OUTER CASINV'(fii ulti-cased:weW,s! ,LINER: fiii licatile ,
FRO�fiTo
DIAMETER THICSMATERIAL
Geological Resources, Inc. ft. in.
Company Name 16:71VNER GASING.OR T BING "eo hernial closed=loo"
WM-0701255 FROM TO I DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 5 tt. 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 vx�,,r„_ ._..�_
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5 ff 15 ff 2 in. 0.010 sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 8 GROUT .3; r_
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 3 ft. grout , pour
Non-Water Supply Well:
17Monitoring ❑Recovery 3 ft. 4 ft. bentonite pour
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation9.SAND/GRAGEL PACK{'tf,a"licible __. ; '; a
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
4 15 'sand pour
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20 DRILLING I OG°attach addifionafsheets if,necessa;{� ..
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soit(rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 0.5 ft Top soil
4.Date Well(s)Completed: 10/27/2021 Well ID#M W-7 0•5 rt. 5 rt. Medium brown sand
5 ft- 15 ft. Tan clay
5a.Well Location:
Holiday Food Mart 00-0-0000025052
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
3 NC Hwy 32 N, Sunbury, NC 27979
Physical Address,City,and Zip 21:RE)•7ARKS ', - i
Gates 7908380110000 DEC 2 2 2021
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: '`,f
(if well field,one lat/long is sufficient) 22.Certification: ���as + PInrI�'SSM t/Ial
36.4415600 N 76.6100420 W J��'" 11/5/2021
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 END copy ofihi.s 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 ofthis 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: 15 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells/is/all depths if dierent(example-3 ti 200'and 2@100') construction to the following:
10.Static water level below top of casing: unknown tft) 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 flight au 24aabove, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Solid auger 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
24c.For Water Supply&Injection i n Wells:
13a.Yield(gpm) Method of test
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.
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Form GW-I North Carolina Department of Environment and Natural Resources—Division of WaterResources Revised August 2013
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