GW1-2021-02180_Well Construction - GW1_20210721

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: �y
Justin Radford RF N 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name A021 e. ft.
3270 A JUL L ft. ft.
NC Well Contractor Certification Number tlOn
processing Unit 15.OIITER CASING:for multi-citsQ*cps OR=LINER if 4""Hdable*.
Inlof�3 Don section mom TO DIAMETER MCKNESS MATERIAL
Geological Resources, Inc. `
ft ft. in.
Company Name `16.`INNERCASING"OR TUBING: eothermal:dosed=lodI
FROM TO DIAMETER I THICKNESS I MATERIAL
2.Well Construction Permit#: 0 ft' 3 ft. 2 in. sch 40 PVC
List all applicable well permits(i.e.County,State,Variance,Injection,etc) ft. ft. in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
❑Agricultural ❑Municipal/Public 3 fL 13 ft. 2 i°' 0.010 sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. it in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT''
FROM I TO �v MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hri ation 0 fL 0.5 ft. Grout Pour
Non-Water Supply Well:
©Monitoring ❑Recovery 0.5 ft. 2 fL Bentohite Pour
Injection Well: R• ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ifii 'Idiible FROM TO MATE ,
RL►I. EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 2 ft' 13 ft. ;Sand
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control :20.DRILLING'LOG sittachiidditional sheets"itnedessa`"
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRWHOx color,hardness soWrock ` s etc.
❑Geothermal (Heating/Cooling Return ❑Other(explain under#21 Remarks 0 ft ft- Orange sandy clay
4.Date Well(s)Completed: Well ID#
05/26/2021 MW-11 2 ft' 5 ft. Dark brown fine sand
ft. ft.
5a.Well Location: ft. ft.
Shields Exxon-Aberdeen 0-000020676 ft. ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
100 North Sandhills Blvd, Aberdeen, NC ft. ft.
Physical Address,City,and Zip 21:REMARKS
Moore 8570-1313-9659
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
35.133448 N 79.428249 W ° 1 06/23/2021
Signature of Certified Well Contractor: Date
6.Is(are)the well(s): 2Permanent or ❑Temporary By signing this form,I hereby certify that the 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 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 an the back ojthis 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 form. SUBMITTAL INSTUCTIONS j
9.Total well depth below land surface: 13 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ij different(example-3@200'and 2@100) construction to the following:
i
10.Static water level below top of casing: 7.6 (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.) p 24b.For Infection Wells ONLY: In addition to sending the form to the address in
6" Solid Fli tit Auger 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
13a.Yield(gpm) Method of test:
24c.For Water Supply&Injecdon'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-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013