GW1-2021-02182_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:
'N Justin Radford ',_44.WATER ZON]KS
FROM TO I DESCRIPTION
Well Contractor Name ft ft.
3270 A & ft.
NC Well Contractor Certification Number 15.011JTERCAS2!��Od wells). RLINEIII "6ble);;
_
kin" FROM TO I DIAMETER ?THICKNESS MATERIAL
Geological Resources, Inc
ft. ft- in.
L)vv 16.INNER CASINGOR
Company Name TUBING(iedtherr&I dosed4o6fiY
FROM TO I DIAMETER T THICKNESS MATERIAL
I 1
2.Well Construction Permit#: 0 ft 3 ft- 12 in. soh 40 PVC
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
& ft. in.
3.Well Use(check well use): -
'17.SCREEN,_ X_
Water Supply Well: FROM I TO I DIAMETER SLOT SIZE THICKNESS I MATERIAL
OAgricultural OMunicipal/Public 3 & 113 & 12 't'- 0.010 sch 40 PVC
[]Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft.
DIndustrial/Commercial DResidential Water Supply(shared) 18:GROUT T'�
'W
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
01nigation 0 'L 0.5 ft- Grout Pour
Non-Water Supply Well: 0.5 ft- 2 ft- Bentonite Pour
laMonitoring ORecovery
Injection Well: ft. ft.
OAquifer Recharge CGroundwater Remediation 19.SAND/GRAVEL,P'kC if ap%pikable)
DAquifer Storage and Recovery OSatinity Barrier FROM TO MATE EMPLACEMENT METHOD
2 it' 13 ft. Sand Pour
OAquifer Test OStormwater Drainage
& ft.
0 Experimental Technology 0 Subsidence Control
.20.DRILLING LOG'ittath additi6iial
DGeothermal(Closed Loop) OTracer FROM I TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
OGeothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks 0 it- 2 ft Brown fine sand
05/26/2021 MAO 2 ft 5 ft.
Dark brown fine sand
4.Date Well(s)Completed: Well #ID
5a.Well Location: 5 7 Tan clay/sand mix
7 fL 8 ft. Tan clay
Shields Down-Aberdeen 0-000020676
Facility/Owner Name Facility 1D#(if applicable) ft
100 North Sandhills Blvd, Aberdeen, NC ft ft.
Physical Address,City,and Zip
Moore 8570-1313-9659
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:
N79.428249 W 06/23/2021
Signature of Certified Well Contractor, Date
6.Is(are)the well(s): 121Permanent or OTemporary By signing this form,I hereby cer*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: OYes or E]No copy ofthis 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 i
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: 13 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@200'and 2@1001 construction to the following:
10.Static water level below top of casing: 8.17 -00 Division of Water Re"sources,Information Processing Unit,
V'water level is above casing,use"+ 1617 Mail Service'Center,Raleigh,NC 27699-1617
11.Borehole diameter:.6 (in.) 24b.For Iniection Wells ONLY: 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: 6" Solid Flight 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(Center,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