GW1-2022-01705_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 WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
3220 A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for maltigELeId wells OR LINER if a lieable
FROM TO DIAMETER THICKNESS MATERIAL.
Geological Resources, Inc. ft. ft. I in.
Company Name 16.INNER CASING OR TUBING eothermal dosed-loon)
WS0601187 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft' 2 ft- 2 i°' sCh 40 PVC
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
fr. fr. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Pubfic 2 ft' 22 ft' 2 in. 0.010 sch 40 PVC
[]Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commerrial ❑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:
OMonitoring ❑Recovery
0.5 ft 1.5 ft Bentonite Pour
Injection Well:
[I Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery []Salinity
TO MATERIAL EMPLACEMENT METHODSalinity Barrier 1.5 ft. 22 ft' Sand Pour
❑Aquifer Test ❑Stormwater Drainage fr. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION color,hardness soil/rack type in size eta
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 rt. 0.5 ft. Concrete
12/13/21 MW-16 0.5 ft 15 Gray medium sand
4.Date Well(s)Completed: Well 1D# 15 ft• 17 ft. Light gray Clay
Sa.Well Location:
17 ft 22 ft. Tan fine sand
Community Stop #2 00-0-0000018540
Facility/Owner Name Facility 1D#(if applicable) ft ft.
150 West Martin Luther King Drive, Maxton, NC ft. rt.
Physical Address,City,and Zip 21.REMARKS
Robeson 8395-4960-0700
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one lat/long is sufficient)
34.7361104 N 79.3512063 W 12/17/21
Signature of Certified Well Contractor Date
6.Is(are)the well(s): 21'ermanent 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 I5A NCAC 02C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 0No 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#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: 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 farm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 22 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 a200'and 2@1001 construction to the following:
10.Static water level below top of casing: 9.50 (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: 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: 9 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
24c.For Water Supply&Injection 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-1 North Carolina Department of Environment and Natural Resources-Division of Wate I r Resources Revised August 2013