GW1-2021-02155_Well Construction - GW1_20210721

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: I I
Justin Radford ® 14.WATER ZONES
FROM TO I DESCRrP ON
Well Contractor Name ft. ft
3270 A Ti. ft.
111 ffbt
NC Well Contractor Certification Number 15.OUTER CASING multi
sed Wells) LINER if iO
proce FROM To TIMETER THICKNESS MATERIAL
Geological Resources, Inc. Si,�&Oln ft. ft.
Company Name 16.INNER CASING OR TUBING f#i!6the'rihiI 616-aAdAiiAiiI
THICKNESS MATERIAL
2.Well Construction Permit#:WM0701242 FROM TO DIAMETER in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc) 0 ft 2 ft 2 sch 40 PVC
ft. ft. I in.
3.Well Use(check well use):
17.SCREEN.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural []Municipal/Public 2 'L 8.64 It- 2 in 0.010 FSCh 40 PVC
OGeothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in I
DIndustrial/Commercial OResidential Water Supply(shared) 19.GROUT
DIrriRation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply W-e-11-T 0 ft' 0.5 ft- Grout Pour
19Monitoring DRecovery ft. ft.
Injection Well:
ClAquifer Recharge OGroundwater Rernediation -19.SAND/GRAVEL'PACK'flf ObIDUC11ble)
OAquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
0.5 ft. 1 ft Bentonite Pour
OAquifer Test OStormwater Drainage
C Subsidence Control ft.
OExperimental Technology 1 ft- 8.64 Sand Pour
20.DRILLING'LOG(afte
OGeothermal(Closed Loop) OTracer FROM To DESCREPTION(color,hotness,soillrock type,grWn si etc.)
OGeothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) 0 fL 2 ft Brown fine sand
t-
4.Date Well(s)Completed: 04/27/2021 Well IDA f�-47 P\ 2 f 6 ft.- Gray clay
6 It- 8.64 ft. Gray fine sand
5a.Well Location: ft. ft.
Perry's Grocery/Harrell's Gulf 00-MO00030286&00-0-0000022919 ft. &
Facility/Owner Name Facility ID#(if applicable)696 NC Hi ft. ft.
ghway 42, Trap NC, ft. ft.
Physical Address,City,and Zip
Bertie 6920-80-2641 Well re-drilled due to damaged casing.
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certifl at!
(if well field,one lattlong is sufficient)
36.206222 N76.869722 W 05/28/21
Signature o 'fied Well Contra CK Date
6.Is(are)the well(s): la Permanent or OTemporary By signing this form,I hereby-n6 that I well(s)was(were)constructed in accordance
with 15A 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 ONo 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:
1 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: 8.64
-(ft.) 24a. For All Wells: Submit this4 form within 30 days of completion of well
For multiple wells list all depths ifilifferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 1 .30 (ft.) Division of Water Reso f urces,Information Processing Unit,
If water level is above casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 3.5
(in.) 24b.For Iniection Wells ONLY: j In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Hand Auger 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 C e�nter,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-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013