GW1-2021-02408_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: ��CEI ED
Justin Radford 14�VVATER=ZONES�: �
FROM TO DESCRIPTION
Well Contractor Name JUN X ] 2021 10 n• 15 ft• Ilimesto'ne w/tan medium sand
3270 A
essing Unit
NC Well Contractor Certification Number Inforr�,atton Proc 54013TER CASINGS fd�,:uittlti=casivl wells yORtiINERf a licselile �""`
Geological Resources, Inc. DWR Section FROM TO DIAMETER THICKNESS MATERIAL
ft. I ft. I ' in.
Company Name 1''0lNNER;CA9INO;0RJTUBING'!eoohermal(close�,too` `
FROM TO DIAMETER 'THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 5 ft. 2" in. sch 40 PVC
List all applicable well permits(i.e.County,State, Variance,Injection,etc)
ft. ft. in.
i
3.Well Use(check well use): ?A`7i'SCREEN,
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5 ft' 15 ff• 2 1°' 0.010 sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) &* R'OU� d
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 rt. 3 ft. Concrete Pour
Non-Water Supply Well:
©Monitoring El Recovery
3 ft. 4 ft. bentorjite pour
Injection Well:
❑Aquifer Recharge ❑GroundwaterRemediation 09(SAND%GRA ELIJAGKdif-a licab'le
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHODft. ft.
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 4 15 0DR7LLr1NGt �G aeh adainoSand Pour
0 '" al�shee`t'slif,necessa'. >
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRH'TION color,hardness,soit/rock type,grain size,etc
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) 0 ff• 0.5 ff• Asphalt
4.Date Well(s)Completed: 04/05/2021 Well ID#GMW-1 0.5 ft- 1.5 ft. ABC gravel
1.5 ft- 10 ft. Tan medium sand
Sa.Well Location: 10 ft. 13 ft. Gray clay(wet)
Home Race Mart#3 0-00-0000035650 13 ft. 15 ft. Limestone with tan medium sand (wet)
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
208 Old Hwy 74/76 E, Lake Waccamaw, NC ft. ft.
Physical Address,City,and Zip21REMARKS ,
<..: _ .
Columbus 1240.02-58-2753
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)
34.322413 N 78.518809 W 04/23/21
Signature of Certified Well Contractor Date
6.is(are)the well(s): 2Permanent or ❑Temporary By signing this form,1 hereby certify that the wells)was(were)constructed in accordance
with 1 JA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or END copy ofthis 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 421 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 oneform. 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 if dierent(example-3@200'and 1 @100') construction to the following:
10.Static water level below top of casing: 10.58 (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 3.5 (in.) 24b. For Infection Wells ONLY In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
Hand Auger
12.Well construction method: construction to the following: i
(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
�gP ) 24c.For Water Supply&Injection:Wells:'
m 13a.Yield Method of test: i
Also submit one copy of this forth within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed. p
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013