GW1-2021-01993_Well Construction - GW1_20210620

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
John Allen 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
4196-B 8 ft- 5 k.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for mu -cased wells OR LINER if lti bk
ETFROM TO DIAMETER THICKNESS I MATERIAL
0 fL 5 k• 2" SCH40 PVC
Company Name
W M 0701249 16.INNER CASING OR TUBING eotherasal closed-loop)
2.Well Construction Permit#' FROM TO DIAMETER 9HICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft k. in
3.Well Use(check well use): 17. ft k. in
Water Supply Well: FROM E TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E)MunicipaUPublic 5 k- 15 ft• 2" 1n. 0.010 SCH40 PVC
Geothermal(Heating/cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) I&GROUT
I-IIrrt ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 2 k• Neat Cement Poured Through Augers
x Monitoring Recovery 2 ft 4 k• Bentonite Poured Through Augers
Injection Well: ft. k.
Aquifer Recharge E3Groundwater Remediation
19,SANDlGRAVEL PACK if a ble
Aquifer Storage and Recovery E3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ❑Storm water Drainage 4 ft• 15 k• #2 Sand Pour Through Augers
Experimental Technology Subsidence Control IL &
RGeothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets N
Geothermal(Heating/Cooling Return) r3Other(explain under#21 Remarks) FROM TO DESCRQ'TION color,bardne soit/mck tyM grain size,etc
ft. IL See Consultant's Logs
4.Date Well(s)Completed: 6/2/2021 well ID# MW-8 ft. k.
s
Sa.Well Location: ft. k.
Univar Solutions USA Inc. ft. n
Facility/Owner Name Facility ID#(if applicable) ft. k Q
403 Neuse Rd., Kinston, NC, 28501 ft. k. IrIG Ul,it
Physical Address,City,and Zip k k' jr&33rf,'310, L` r YiQfl
Lenoir 21•REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: —
(if well field,one latflong is sufficient) 22.Certification-
35.2378369 N 77.5432976 W 0't& 6/17/2021
6.Islam)the well(s)ox Permanent or Temporary Signatur1111151orm,
erlitied Well Contractor Date
By signi I hereby cernA that the well1s)was(were)constructed in accordance
7.Is this a repair to an existing well: E)Yes or XQNo with 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the mature of the copy of this record has been provided to,he well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also.attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
t
9.Total well depth below land surface: 15 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiJjerent(example-3@200'and 2(&100') construction to the following:
10.Static water level below top of casing: 8 (ft.) Division of Water Resources,Information Processing Unit,
Ifwaier level is above casing,use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8 1/4'r (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Auger above,also submit one 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& Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13&Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-t North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016