GW1-2021-02403_Well Construction - GW1_20210601

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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 �14.WATER ZONES _.
FROM TO DESCRIPTION i
Well Contractor Name ft. 'Z ft- Pr jlk5 GrC'CD U$i/
3270-A ft ft
NC Well Contractor Certification Number "15.,'OUTER CASINGS(for eased dells OR'L iER if a Yisible
FROM TO DIAMETER THICKNESS MATERIAL
Geological Resources, Inc. ft. ft
Company Name 16.-INNER CASINGOR TUBING'eothermal,closed46o't,
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: N/A 0 % 2 ft 2 in. sch 40 PVC
List all applicable well permits#.e.County,State,Variance,Injection,etc) ft fL in.
3.Well Use(check well use): 17.+SCREEN 3: Al
Water Supply Well: FROM TO 4 DIAMETER SLOT SIZE THICKNESS _MATERIAL
❑Agricultural ❑Municipal/Public 2 ft 12 ft 2 in. 0.010 sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft ra
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.iGROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hri ation 0 fa 0.5 ft grout ' pour
Non-Water Supply Well:
laMonitoring ❑Recovery 0.5 tt 1 bentonite pour
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL'PACK(if.a Hcible
FROM TO.. MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 1 ff 12 ft. #2 sand pour
❑Aquifer Test ❑Stormwater Drainage
ft ft
❑Experimental Technology ❑Subsidence Control
2&MIULLINGLOG:attiith''additional'Aeet`sifiie iKa . a
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soiVrock grain;& eta
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 6 ft Air knife;no recovery
4.Date Weil(s)Completed: Well ID#
05/12/21 MW-5 6 ft- 12 ft DPT;no recovery
ft ft
5a.Well Location: ft ft
Speedway#8294 0-000036034 ft ft
Facility/Owner Name Facility ID#(if applicable)
ft ft
550 US Highway 264 Bypass, Belhaven, NC ft % '
Physical Address,City,and Zip J V N X
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Beaufort 7606-53-1313 a1:�xEMARKs � - �
Information Process'
County Parcel Identification No.(PIN) UVVM
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22 Certification:
(if well field,one lat(iong is sufficient)
35.5494360 N 76.6291770 W o� Zl Zi
Signature of Certifiv,Well Contract Date
6.Is(are)the well(s): OPeemanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with ISA 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 E]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!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: 12 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii erent(example-3@200 and 1@I00) construction to the following:
10.Static water level below top of casing:
3.24 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service CI nter,Raleigh,NC 27699-1617
11.Borehole diameter: 3.5 (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 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
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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
136.Disinfection type: Amount well construction to the county health department of the county where
constructed. i
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Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013