GW1-2021-02402_Well Construction - GW1_20210601

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells f
1.Well Contractor Information: 4
Justin Radford 14;WATERZONES . - � .
FROM TO DESCRIPTION
Well Contractor Name fL 12 ft P lL k/v0 rLGOVer
3270-A ft ft
NC Weil Contractor Certification Number =35 OUTER CASING for multi-eased`wells OR LINER if a' ]tcableMATERIAL
6
FROM TO DIAMETER THICKNESS
Geological Resources, Inc. ft ft
Company Name J&INNER CASING OR=TUBING'"eothefmal cldied400 ,
FROM TO DIAMETER THICKNESS _ 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): 17.SCREEN
Water Supply Well: FROM I TO DUMETER il SLOT SIZE I THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public 2 ft 12 fc 12 in'i 0.010 sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. 1n.
IS.GROUT _ w <,.
❑Industrial/Commercial ❑Residential Water Supply(shared) FROM To MATERIAL _ EMeLACEMErrr METHOD&AMOUNT
❑Irri ation 0 fL 0.5 % grout pour
Non-Water Supply Well:
19Monitoring ❑Recovery 0.5 1 tt bentonite pour
Injection Well: ft. tt
❑Aquifer Recharge ❑Groundwater Remediation I9:SAND/GRAVEL"=PACK' ,a licetile ,, t= 7_5
❑Aquifer Storage and Recovery ❑Salinity Barrier
FROM TO ft MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 1 fL 12 #2 sand pour
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG.ittaeh;additlonil4aheets if.eceasa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,solVrock size etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft ft Air knife;no recovery
4.Date Well(s)Completed: 05/12/21 well ID#MW-2 6 fL 12 ft DPT;no recovery
ft. ft.
Sa.Well Location: ft. ft
Speedway #8294 0-000036034 ft. ft.
Facility/Owner Name Facility M#(if applicable)
550 US Highway 264 Bypass, Belhaven, NC � ft
Physical Address,City,and Zip
2I REMARKS ?,
Beaufort 7606-53-1313 In rMatlon Proce. _.
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 L2_1
Signature o ertified Well ontractor 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 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or EINo 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'aand 2@1001 construction to the following:
10.Static water level below top of casing: 1 L� (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service C tinter,Raleigh,NC 27699-1617
11.Borehole diameter. 31 (in.) 24b.For Iniection Wells ONLY:I 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 tire 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.
i
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013