GW1-2021-02560_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:
,14.WATER ZONES - r
Sam Bowers a.� FROM TO DESCRIPTION
Well Contractor Name v ft. ft
3220-B I lj �y 20�1` 15 OUTER CASING for multi-case )
NC Well Contractor Certification Number J tl wells OR LINER if a licable
I®,rasing ulti FROM TO DIAMETER THICKNESS MATERIAL
Geological Resources, Inc. ,atton Pft.
Company Name
V IN 16.INNER CASING OR TUBING e6thermal closed-loop),
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 it. 2 ft. 2 1° soh 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 I)MMETER SLOT SUE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 2 ft 12 ft 2 l°` 0.010 sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 1 fL Concrete
Non-Water Supply Well:
ft. ft.
RMonitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19 SAND/GRAVEL PACK if a Wable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
1 ft• 1.25 fL Bentonite
❑Aquifer Test ❑Stormwater Drainage
❑ ❑Experimental Technology Subsidence Control 1.25 ft 12 ft Sand
20:DRILLING"LOG. attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,sell/rock type grain size,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 0.25 fL Asphalt
4.Date Well(s)Completed: Well ID#
03/11/2021 MW-1 0.25 ft- fQ Orange medium sand to clay mix
5 1" 12 ft. Gray and orange medium sand to clay mix
5a.Well Location: ft. ft.
Benson Food Mart 0-0000001859 ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
605 East Main Street, Benson, NC ft. ft.
Physical Address,City,and Zip 21.REMARK5 ,:
Johnston 01023040
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one lavlong is sufficient) ,u
. 35.378107 N 78.541704 W 04/07/21
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 15A 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 E]No copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction in/ormation and explain the nature of the
repair under#21 remarks section or on the back o/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 farm. 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'and 2@1001 construction to the following:
1 10.Static water level below top of casing:4.90 tfL) Division of Water Resources,Information Processing Unit,
I/water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
i
11.Borehole diameter: 6 (in.) 24b.For Injection Wells ONLY: In addition to sending the form to the address in
Rota Au er 24aabove, also submit a copy of this form within 30 days of completion of well
12.Well construction method: 9 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