GW1-2021-02401_Well Construction - GW1_20210601

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: '
J 14.WATER ZONES
Justin Radford F, ?"
FROM TO DESCRIPTION
Well Contractor Name l it. 12, % K'f,to ML0V e V
3270-Aft. fL
NC Well Contractor Certification Number „d5.OUTER CASING(for mu1 cased wells ORI INEW if a hcable
FROM TO DIAMETER THICKNESS MATERIAL
Geological Resources, Inc. f, ft. in.
,
Company Name 16.`NTNER'CASING ORLTUBING el thermal elosed-loo"1
FROM TO DIAMETER IIN R T®CESS MATERIAL
2.Well Construction Permit#: N/A 0 ft 2 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): :SCREEN'-'-,
Water Supply Well: FROM To DIAMETER SLOT SLZE TRICKINESS MATERIAL
[]Agricultural ❑Municipal/Nblic 2 It. 12 fL 2 1°' 0.010 Sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft in.
❑hrdustriaUCommercial ❑Residential Water Supply(shared) 1 18 GROUT
FROM TO MATERUL EMPLACEMENT METHOD&AMOUNT
❑irri tion 0 it. 0.5 ft a grout pour
Non-Water Supply Well:
0.5 tt 1 ft bentonite pour
2Monitoring ❑Recovery
Injection Well: IL ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVED PACK Ifii licatile
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 1 fL 12 ft. #2sand pour
ft. ft.
❑Experimental Technology ❑Subsidence Control
20 DRILLINGiLOG"a"ttiich:additlooa[sheefi If;rttcessa ,
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,sollfruck n dze etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft ft Air knife;n0 recovery
4.Date Well(s)Completed: 05/12/21 well ID#MW-3 6 ft. 12 ft. DPT;no recovery
ft. ft.
5a.Well Location: ft ft.
Speedway #8294 0-000036034 fL ft
Facility/Owner Name Facility M#(if applicable)
ft. ft.
550 US Highway 264 Bypass, Belhaven, NC ft. ft
Physical Address,City,and Zip
Beaufort 7606-53-1313
n
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)
35.5494360 N 76.6291770 W
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 1 SA NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ®No 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 Ito 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: 12 (ft) 24a. For Ail Wells: Submit this',form within 30 days of completion of well
For multiple wells list all depths iftli Brent(example-3Q200'and 2@100) construction to the following:
10.Static water level below top of casing:4.06 (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 t (in.) 24b.For Infection Wells ONLY: In addition to sending the form to the address in
3.5 DPT 24a above, 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
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-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013