GW1-2021-01995_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 s ft 17 fL
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for mdti�wells OR LINER ifs ' Me
I ET h�
FROM TO DIAMETER THICKNESS MATERIAL
0 fQ 7 ft 2" SCH40 PVC
Company Name 16.INNER CASING OR TUBING urothermal closed-loo
WM0701249
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC.County,Stale,variance,etc.) ft. It. in.
3.Well Use(check well use): ft. ft. _in.
17.SCREEN
Water Supply Well:
pp y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3MunicipaVNblic 7 ft. 17 ft- 2" in. 0.010 SCH40 PVC
Geothermal(Heating/cooling Supply) Residential Water Supply(single) fL ft. is
Industrial/Commercial Residential Water Supply(shared) 1&GROUT
Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fl- 3 h Neat Cement Poured Through Augers
x Monitoring Recovery 3 ft5 ft- Bentonite Poured Through Augers
Injection Well: -
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ❑Stormwater Drainage 5 ft- 17 fL #2 Sand Pour Through Augers
Experimental Technology Subsidence Control fL It.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiltrock rain size,etc)
fL IL See Consultant's Logs
4.Date Well(s)Completed: 6/2/2021 Well ID# MW-6 fL ft.
59.Well Location:
Univar Solutions USA Inc. fL "
Facility/Owner Name Facility ID#(ifapplicable)
ft. ft.
Neuse Rd., Kinston, NC, 28501 ft. ft. - OA A
IAW
Physical Address,City,and Zip ft. ft.
Lenoir 21.REMARKS _
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:
35.2389246 N 77.5437617 W C 1 6"& 4&.1 It, 6/17/2021
6.Is(are)the well(s)Ex Permanent or QlTemporary Signatur41111'slorm,
crtitied Well Contractor Date
By signi I hereby cerl fv that the well/s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or JqNo with 15A NCAC 02C.0100 or I5A 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 beenprovided io the well owner.
repair tmder#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 I GW-1 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: 17' (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths indifferent(example-3@200'and 2@100') construction to the following:
t
10.Static water level below top of casing: 9 (ft.) Division of Water Resources,Information Processing Unit,
Inwater level is above casing,use`•-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8 1/4" (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 SunDly& Infection 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