GW1-2022-01692_Well Construction - GW1_20220131

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Justin Radford '914 WAT;ERZONES
FROM TO DESCRIPTION
Well Contractor Name 6 ft. 13 ft• DPT; no recovery
3270-A ft. rt.
NC Well Contractor Certification Number
_A45 OUTER GIS1Ni toi inuln-cased wells;OR0NER?ifa`b-10h61e "
FROM TO DIAMETER I THICKNESS I MATERIAL
Geological Resources, Inc. ft. ft. I : in.
Company Name
*16INhIERGA9INGF0R'TUBING."eo"thertn51,061ed400
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft' 3 rt. 2 i" SCh 40. PVC
List all applicable well permits(i.e.County,State,Variance,Injection,etc)
ft. ft. in.
3.Well Use(check well use): 2173SCREEN
Water Supply Well: FROM TO DIAMETER _ SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 3 rt• 13 ft. 2 'n 0.010 SCh 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft.
f-118 GROUT
❑Industrial/Commercial ❑Residential Water Supply(shared) FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Uri ation 0 ft. 1 ft. grout ' pour
Non-Water Supply Well:
1 ft. 2 rr. bentonite pour
ElMonitoring ❑Recovery
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation �'19:SAND/GRrtVEI AGK'ifa IicaGie
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 2 ft• 13 ft• sand pour
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
z20ADR1LL1NG�tiOGt"a"tfach additionatisheetstifpecessaT
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soi0rock type,griiin size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 13 ft. DPT; no recovery
4.Date Well 1/03/2022 s)Completed: Well ID#M W-2 ft. ft.
ft. ft.
5a.Well Location: ft. fa
Speedway #8278 0-035493 ft. ft. _
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
2535 West 5th Street, Washington, NC 27889 ft. ft. `
Physical Address,City,and Zip � . fm
21REMA`RIGS�s.-r� � �,� �` .,. �v s-
Beaufort 5667-63-3508
County Parcel Identification No.(PIN) Y ,l
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwel)field,one IaUlong is sufficient)
35.5857490 N 77.0953160 01/05/2022
Signature of Certified Well Contractor Date
6.Is(are)the well(s): (Permanent or ❑Temporary By signing this form,1 hereby certify that the ivell(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 FIND 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#11 remarks section or on the back of this farm. 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: 13 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3@200'and 2 tD100') construction to the following:
10.Static water level below top of casing: 5.02 (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: 3.5 (in.) 24b. For Infection Wells ONLY: In addition to sending the form to the address in
Direct Push 24aabove, also submit a copy of this form within 30 days of completion of well
12.Well construction method: 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 m Method of test: 24c.For Water Supply&Injection Wells:
(gp ) 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-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013