GW1-2021-02404_Well Construction - GW1_20210601

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
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1.Well Contractor Information:
Justin Radford '14.WATERZONES �.
FROM TO DESCRIPTION
Well Contractor Name ft. 1 2
3270-A It. fL
NC Well Contractor Certification Number >,,15_01JTER CASING for multi-cased wails`OItL1NER itai 16-able
FROM TO DIAMETER THICKNESS MATERIAL
Geological Resources, Inc. it. it, p in.
Company Name 16.INNER CASING ORTUBING eoth4&al'closed400
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: N/A 0 it" 2 ft 2 in. sch 40 PVC
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. fL in.
3.Well Use(check well use): 17.`SCREEN, f t � •`-
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Pubfic 2 IL 12 ft. 2 In.' 0.010 sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) I'L ft in•
❑Industrial/Commercial ❑Residential Water Supply(shared) GROUT.
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hri ation 0 ft' 0.5 it. grout ' pour
Non-Water Supply Well:
laMonitoring ❑Recovery 0.5 ft- 1 ft bentonite pour
Injection Well: ft. &
❑Aquifer Recharge ❑Groundwater Remediation �A%SAND/GRAVEL1ACK?if
MPLACE
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL E MEW METHOD
1 fL 12 ft- #2 sand pour
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control '10.DRILLING"LOG,atta`ch;addidons"i"sheet If,*fiecessi ' s 4�
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIMON color,hardness,soil/mck 4Ve,grain gize,etc \
❑Geothermal eating/Cooling Return ❑Other(explain under#21 Remarks) 0 ft 6 ft oAir knife;no recovery
05/12/21 MW-4 6 fL 12 DPT;no recovery
4.Date Well(s)Completed: Well ID# 4.
fL &
5a.Well Location: fL ft Li
Speedway #8294 0-000036034 fL ft.
Facility/Owner Name Facility EM(if applicable) tL fL J UiV
550 US Highway 264 Bypass, Belhaven, NC tt rlqUnit
Physical Address,City,and Zip ,
Beaufort 7606-53-1313 .521• ���
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one laUlong is sufficient)
35.5494360 N 76.6291770 W
Signature of Certified Well Contractor Date
6.Is(are)the well(s): laPermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or I SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 0No 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
S.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
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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'and 2@1001 construction to the following:
10.Static water level below top of casing: 4.61 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+"` 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 1 J (in.) 24b.For Infection Wells ONLY: 1n addition to sending the form to the address in
3.5 DPT 24a above, also submit a copy of ithis form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) ' r
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 depaitment of the county where
constructed. S
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Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013