GW1-2021-01994_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- 15 ft-
ft. h.
NC Well Contractor Certification Number 15.OUTER CASING for mWtl eased weW OR LINER if a 61e
ETFROM TO DIAMETER THICKNESSI MATERIAL
0 ft. 5 ft 1 2" SCH40 PVC
Company Name
W M 0 7 0124 9 16.INNER CASING OR TUBING eherml timed-lao
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft in.
3.Well Use(check well use): It. h. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural [:)Municipal/Public 5 It. 15 fL 2" rn' 0.010 SCH40 PVC
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. h• in.
Industrial/Commercial Residential Water Supply(shared) Ill.GROUT
Irrl atlon FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 2 ft, Neat Cement Poured Through Augers
X Monitoring 0 Recovery 2 fL 4 ft- Bentonite Poured Through Augers
Injection Well: ft. fL
Aquifer Recharge Groundwater Remediation
19.SANDlGRAVEL PACK a bk
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ❑Stormwater Drainage 4 h 15 ft #2 Sand Pour Through Augers
Experimental Technology Subsidence Control h h.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional shaft if
I gGeothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,wil/mk rain six,etc
fL fL See Consultant's Logs
4.Date Well(s)Completed: 6/2/2021 Well ID# MW-7 fL h.
59.Well Location: ft. h•
Univar Solutions USA Inc. ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft' 02
357 Neuse Rd., Kinston, NC, 28501 h. ft. re
Physical Address,City,and Zip ft. ft.
Lenoir 21•f MARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.2368689 N 77.5447105 W
6/17/2021
6.Is(are)the well(s)ox Permanent or Temporary Signature u ulifted Well Contractor Date
Hy signi (his/itrm,1 hereby cerit/i that the wells)was(were)constructed in accordance
7.is this a repair to an existing well: [:)Yes or XQNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under 41 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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
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 if different(example-3(a),2(N)'and 27q)I o0') construction to the following:
r
10.Static water level below top of casing: $ (ft.) Division of Water Resources,Information Processing Unit,
!f water level is above casing,use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8 1/4" (in.) 24b. For Iniection 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
l2.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& Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016