GW1-2022-01695_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 Ia MIATERZONE9J1Jk- ,��
FROM TO DESCRIPTION
Well Contractor Name 12 ft. 19 ft. Direct Push; no recovery
3270 A ft. ft.
NC Well Contractor Certification Number ,4S.�OUTER;CA`SING for al"ti-cased wells`;OR INER ifslicali
FROM TO DIAMETER THICKNESS MATERIAL
Geological Resources, Inc. rr. ft. in.
Company Name 16A NNE RICAS1NG QRaTUBINGf`eoffie`rmal closed06-o
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 9 ft. 2 in. sch 40 PVC
List all applicable hell permits(i.e.County,State, Variance,Injection,etc)
ft. ft. in.
3.Well Use(check well use):
y'r17ASCsREEN.y�
Water Supply Well: FROM TO DIAMETER i SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic 9 ft. 19 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) FROM R�U� TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 5 ft. grout pour
Non-Water Supply Well:
5 fr. 7 rt. bentonite pour
Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation d9SADIGRAi LPACKi lfa►icabie
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
7 fr. 19 ft. sand pour
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control . ,
*20:�DRIlILI:ING�I;OG1a'"itefiladdiiionalslieetslifnece ssa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(coW,hardness,soil/mck type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 0.5 ft. Gravel
4.Date Well(s)Completed: Well ID#
12/20/2021 MW-1 0.5 r' 10 ft. Orange fine sand
10 rt. 12 ft. Gray medium sand with clay
S Location:
Kwik Korner 00-0-0000033451 12 ft. 19 ft. DPT; no recovery.
Gary's
ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft ft
119 East Hamlet Street, Pinetops, NC 27864 ft. ft '-
Physical Address,City,and Zip , VREM[XR 5 - •` `�
Edgecombe 4704-45-3567 v
County Parcel Identification No.(PIN)
1.
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one lat/long is sufficient)
35.7909330 N 77.636528° W p 01/05/2022
Signature of Certified Well Contractor Date
6.Is(are)the well(s): [OPermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(mere)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 ElNo 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 421 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
.I
9.Total well depth below land surface: 19 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tfdierent(example-3@200'and 2@l00') construction to the following:
10.Static water level below top of casing: 1 2.61 (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(gpm) Method of test 24c.For Water Supply&Injection Wells:
Also submit one copy of this foim within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
Form G W-1 North Carolina Department of Environment and Natural Resources—Division of Water,Resources Re%rised August 2013