GW1-2021-02193_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:
Justin Radford A4YAV�ATERZONES
R FROM TO DESCRHPTION
Well Contractor Name 6 ft' 15 ft' ! Gray silty sand
3270 A % 1 2021 ft. ft.
NC Well Contractor Certification Number jn�t 15.;OUTER CASING for:multi eesetl wells O NI ER'if a licatile
�,COceSs%ng FROM TO DIAMETER THICKNESS MATERIAL
Geological Resources Inc. tr,,at0�1 ,,: n ft. rt. In
9 �rria PPR SIB
Company Name AOINNER CASING OR;TUBINGI eothermal closed=too
WM-0601174 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 5 ft. 2" '"' sch 40 PVC
List all applicable well permits(i.e.County,State, Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): v17SC,REEN =' v ' il! z s „
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5 ft. 15 ft• 2 '"' 0.010 sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.'
❑Industrial/Commercial ❑Residential Water Supply(shared) .,18.!GROUT . 4
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hTi ation 0 ft' 2 ft- Grout
Non-Water Supply Well: Four
@Monitoring ❑Recovery 2 ft. 3 ft. Bentonite Pour
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation r19:)SAND/GRAV;EUiP CK if,a" icaable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
3 ft. 15 ft. Sand
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
20.xDRILLING°tiOG attiicti,adilitionalsheefsif_oeee did
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,gnin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 0.5 ft. Asphalt
05/27/2021 MW-28 0.5 rt. 5 rt. Dark gray sandy silt
4.Date Well(s)Completed: Well ID# 5 rt. 7 rt. Light gray well sorted crop sand
5a.Well Location: 7 ft• 11 ft• Light gray silty sand
Minute Man #24 0-00-0000018669 11 ft 15 rt Brown cmfsand
Facility/Owner Name Facility ID#(if applicable) ft. ft.
5102 Fayetteville Road, Lumberton, NC
Physical Address,City,and Zip %2 1 sREMARKS 4,69W .., _ ?. `-
Robeson 9393-7586-2100
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification.
(if well field,one tat/long is sufficient)
34.672056 N 79.007667 W 06/09/2021
Signature of Certified Well Contractor Date
6.Is(are)the well(s): 2Permanent or ❑Temporary By signing this form,I hereby certify that the wells)was(were)constructed in accordance
with LiA 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 ENO copy ofthis record has been provided to the well owner.
Ifthis is a repair,fill out known well construction information and explain the nature ofthe
repair under 921 remarks section or on the back ofthis 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: 15 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iftli ferent(example-3@200'and 2@l00') construction to the following:
10.Static water level below top of casing: n/a (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Clenter,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b. For Injection Wells ONLY:!In addition to sending the form to the address in
6" Rota Au 24aabove, also submit a copy of this form within 30 days of completion of well
12.Well construction method: '1-7�� 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
m Method of test: 24c.For Water Supply&Injection Wells:
13a.Yield(gp ) 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