GW1-2022-10496_Well Construction - GW1_20221118

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
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14.WATER ZONES
Matt Steele FROM TO DESCRIPTION
Well Contractor Name ft. I ft.
4548 A ft ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
Geological Resources, Inc. ft. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
WM-0501508 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft• 15 ft• 2 in sch 40 PVC
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft, I ft. I in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 15 ft' 30 ft. 2 in. 0.010 sch 40 PVC
❑Geothermal(Heating/Cooling Supply) El Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
[Irrigation 0 rt. 10 ft. Grout Pour
Non-Water Supply Well:
10 ft 13 ft Bentonite Pour
RMonitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge El Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery []Salinity Barrier 13 ft. 30 ft. Sand
[]Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness soil/rock in size,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 6 ft. Brown silt
4.Date Well(s)Completed: 1 0/04/22Well ID#GMW-4 6 ft 18 ft. Red silt
18 ft 24 fL Red silt
5a.Well Location: ft. ft
24 30 .�, jted silt
Former J.M. Daniel Grocery 00-0-0000000233 ft. ft. r N�7-tQ V -
Facility/Owner Name Facility ID#(if applicable)
2226 NC Highway 4, Littleton, NC ft. ft. NOV
ft. ft.
Physical Address,City,and Zip 21.REMARKS
Halifax 0700853 V t�/ Cfia `
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22:rr rlifiC mon-
36.392259 N 77.9000065 W '" G= 11/08/2022
Signature of Certified Well Contra,. Date
6.Is(are)the well(s): ©Permanent 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 ONo 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: 30 (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 2@100) construction to the following:
10.Static water level below top of casing: n/a (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
Solid fli ht au er 24aabove, also submit a copy of this form within 30 days of completion of well
12.Well construction method: g g 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