GW1-2022-01699_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:
Sam Bowers 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
3220 A
ft. ft.
NC Well Contractor Certification Number 15.'OUTER CASING for multi-eased_wells
FROM TO ORLNRS :a iM RILT
Geological Resources, Inc. DIAMETER H
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)"
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft 15 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
m.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 15 "' 30 ft 2 '"; 0.010 soh 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fa ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.'GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 ft' 12 ft. Grout Pour
Non-Water Supply Well: 12 ft. 14 ft. Bentonite Pour
[]Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK;if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 14 ft• 30 ft. Sand Pour
[]Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20:DRILLING LOG,attach additional sheets of necessary)
❑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- 0.5 ft. Concrete
4.Date Well(s)Completed: 12/14/21 well ID#MW-8 0.5 rt. 15 ft. Red silt
15 rt. 25 ft. Red medium sand
5a.Well Location:
Daniel's Exxon 0-0009918
ft. ft.
Facility/Owner Name Facility M#(if applicable)
ft. ft. 7
115 East Central Avenue, Raeford, NC ft. ft.
Physical Address,City,and Zip
21.REMARKS
Hoke 6943-4100-1019
County Parcel Identification No.(PIN) l '
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
34.9787508 N 79.2231948 W 12/17/2021
Signature of Certified Well Contractor Date
6.Is(are)the well(s): 2Permanent 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 BNo copy ofthis record has been provided to the well owner.
Ifthis 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: 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: 30 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tf different(example-3 t@200'and 2@100) construction to the following:
10.Static water level below top of casing: unknown (ft) 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 Iniection Wells ONLY: In addition to sending the force to the address in
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 9 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 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-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013