GW1-2021-02184_Well Construction - GW1_20210721

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
TN
1.Well Contractor Information:
Justin Radford qSC 14.WATER ZONEs
FROM TO DESCRIPTION
Well Contractor Name .� 202T- ft. ft
3270 A �'I� unit ft. ft.
rc n 15.`OUTER CASING fo'r multi-caved wells OR LINER s IIcable
�essln
NCWeIIContractorCertificationNumber �ttfi:r(1T3ti�� �B�liO FROM I TO DIAMETER THICKNESS MATERIAL
Geological Resources, Inc. ft. ft. in.
Company Name 16.INNER CASING OR TUBING' el6sed-16661
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 I THICKNESS I MATERIAL,
❑Agricultural ❑Municipal/Public 3 it. 13 ft. 2 in. 0.010 sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft in.
18.GROUT r ': t,�
❑lndustriaUCommercial ❑Residential Water Supply(shared) FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hTi ation 0 ft' 0.5 ft. Grout Pour
Non-Water Supply Well:
COMonitoring ❑Recovery 0.5 f• 2 fL Bentonite Pour
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if ii'"licible
FROM TO MATERIAL I EMPLACEMENT METHOD •"
❑Aquifer Storage and Recovery ❑Salinity Barrier 2 ft 13 ft. Sand Pour
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING.LO+G(attach additiisnal sheets if heeessa ;
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soturock iin sim etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 1 0 ft 1 Brown fine sand
4.Date Well(s)Completed: Well ID#
05/26/2021 MW-12 1 ft. 2 ft. Dark brown fine sand
.
2 ft. 4 ft. Dark gray
5a.well Location: 4 ft' 5 ft. Tan fine sand
Shields Exxon-Aberdeen 0-000020676 ft. ft.
Facility/Owner Name Facility rD#(if applicable)
100 North Sandhilis Blvd, Aberdeen, NC ft
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 06/23/2021
Signature of Certified Well Contractor' Date
6.Is(are)the well(s): mPermanent or ❑Temporary By signing this form,I hereby certify,that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or BNo 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:
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
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-3Q200'and 2@100) construction to the following:
10.Static water level below top of casing: 9.08 (g,) 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.) 24b.For Iniection Wells ONLY: 1n addition to sending the form to the address in
n 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
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 Water Resources Revised August 2013