GW1-2021-00684_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 M4- ATER,ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
3270
NC Well Contractor Certification Number IS.OUTER CASING'for;iitdin-cas'etl,wells*OR>131NER"ifs lic"stile
FROM TO DIAMETER THICKNESS MATERIAL
Geological Resources, Inc. it. ft. in.
Company Name 16.'INNER;CA51�iG;OR UBING'le& ermal_closed=lo' ',
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: N/A 0 ft' 5 rt. 12 t" sch 40 PVC
List all applicable well permits(i.e.County,Slate, Variance,Injection,etc)
ft. ft. in.
3.Well Use(check well use): �17.SCREENi-,Q � .��.�...
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5 ft. 15 ft' 2 in' 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 pour
Non-Water Supply Well:
DMonitoring ❑Recovery 0.5 ft. 4 rt. bentonite pour
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.'SAND/GRAVE0�PACK,if`ii licible
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Battier 4 ft. 15 ft' #2 sand pouf
❑Aquifer Test ❑Stormwater Drainage
ft. rt.
❑Experimental Technology ❑Subsidence Control
20.DRILli1NGliOGa"ftach udditio°i'ial.sheetsif.necessa . � _;'
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soiltrock type,gnin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 0.50 ft- Concrete
4.Date Well(s)Completed: 09/23/21 Well ID#MW-1 0.50 ft• 5 ft. Red silt
5 ft. 10 ft. Red/brown silt
5a.Well Location: 10 ft. 15 ft. Dark brown silt
Speedway #8218 0-00-0000031901 ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. /p �+
112 South Bickette Blvd, Louisburg, NC ft. ft. - --._
Physical Address,City,and Zip 27REMARKS Y :.
Franklin 2805-74-6413
County Parcel Identification No.(PIN) DM SEC7KA
t -
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one]at/long is sufficient) �/ p
36.096592 N 78.295926 09/23/2021
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,1 hereby certify that the wells)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 1 5A NC9C 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or FIND copy ofthis record has been provided to the well owner.
1f this is a repair,fill out known well construction information and explain the nature ofthe
repair under#21 remarks section or on the hack 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.
ror 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 mnthiple wells list all depths if different(example-3@200'and 2 cil100') construction to the following:
10.Static water level below top of casing: 9.04 Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
n
11.Borehole diameter: 6 (in.) 24b. For Infection Wells ONLY: In addition to sending the form to the address in
6" Solid Fli ht Au er 24aabove, also submit a copy of this form within 30 days of completion of well
12.Well construction method: g 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 foIrm within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
i
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water;Resources Revised August 2013