GW1-2021-02183_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:
Justin Radford FROM
wATERZOxEs _ LL
ROM TO I DESCRIPTION
Well Contra ctor Name �� ft. tt
c
3270 A •L 110 n. ft.
NC Well Contractor Certification Number n �gtrr�unit 15,;OUTER CASING for multi-cased wells OR LINER:
pr_,C@� FROM TO DIAMETER THICKNESS MATERIAL
Geological Resources, Inc. �n�cr�3Btiti�R S,3, on ft. ft. ln.
Company Name 16._INNER CASING OR TUBING'('eother6iill elosed;loo
FROM TO I DIAMETER I THICKNESS I MATERW
2.Well Construction Permit#: fL ft. 2" in SCh 40 1 PVC
List all applicable well permits(i.e.Coun)4 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 n ft. l Z ft' 2 in. 0.010 sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
01ndustrial/Commercial ❑Residential Water Supply(shared) 38.-GROUT.,.•.." ..4
FROM I TO MATERIAL. EMPLACEMENT METHOD&AMOUNT4
❑Irri ation ft. 0,4' fi- Grout
Non-Water Supply Well:
OMonitoring ❑Recovery v'S ft. IL i7eti1<'an � _
Injection Well: fa &
[]Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAYELtPACK'if a olicable
TO ft. MATERIAL E LACEMENT METHODMP
❑Aquifer Storage and Recovery ❑Salinity Barrier
FROM ft,
❑Aquifer Test ❑Stormwater Drainage ' ft. I Z ft. Sand
❑Experimental Technology ❑Subsidence Control
20:"DRILLING"L OC'atfac6 s'ddiHonel'dheetsaf
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION color,hardness,soNrock size.etc.)
[]Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 0.5 ft- Concrete
04/14/2021 MW-7 0•5 It. 5 ft- Tan medium sand with clay
4.Date Well(s)Completed: Well ID# 5 fL 12 ft. DPT;no recovery
5a.Well Location: ft fL
Happy Store/301 Convenient Mart 00-0000021687 ft ft
Facility/Owner Name Facility M#(if applicable) ft. fL
1551 North Wesleyan Blvd, Rocky Mount, NC ft, ft
Physical Address,City,and Zip
Nash 3851-1683-6875
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)
i
35.980279 N 77.787538 w 1 oN 2_021
Signature ofCe ed We Con or Date
6.Is(are)the well(s): Permanent Or ❑Temporary By signing this form,I hereby certifylthat the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E)No copy of this record has been provided to the well owner.
Ifthis 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:
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: 12 (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@100) construction to the following:
10.Static water level below top of casing: N/A' (ft.) Division of Water Re sources,'Information Processing Unit,
If water level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:_� y (in.) 24b.For Infection Wells ONLY: In addition to sending the form to the address in
6D 24aabove, also submit a 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
24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test: 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 Watet Resources Revised August 2013