GW1-2022-10497_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:
14.WATER ZONES
Matt Steele FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4548 A ft. ft.
NC Well Contractor Certification Number 15.•OUTER CASING for multi-cased wells OR LINER'if'e 8cable'
FROM TO I DIAMETER I THICKNESS MATERIAL
Geological Resources, Inc. ft. ft. In.
Company Name 16.INNER`CASING OR TUBING&hthermal closed-loo
WM-0501508 FROM TO DIAMETER THICKNESS MATERIAL,
2.Well Construction Permit#: 0 It' 15 It. 2 in' sch 40 PVC
List all applicable wellpermits(i.e.County,State,Variance,Injection,etc)
ft. ft. in.
3.Well Use(check well use): 17.'SCREEN
Water Supply Well: FROM TO DIAMETER SLAT SIZE THICKNESS MATERIAL,
❑Agricultural ❑Municipal/Public 15 ft- 30 It' 2 in• 0.010 sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
8.
❑Industrial/Commercial ❑Residential Water Supply(shared) FR GROUT .'
FROM TO MATERIL
AL EMPLACEMENT METHOD&AMOUNT
[Irrigation 0 ft. 10 ft. Grout . Pour
Non-Water Supply Well:
10 It. 13 ft Bentonite Pour
l7Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK s `licable
� ❑Aquifer Storage and Recovery ❑Salinity Barrier MATERIAL EMPLACEMENT METHOD
FROM TO
13 ft. 30 fr. 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,hardness6 soWrock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 1 0 ft. 1 ft. Gravel/top soil
4.Date Well(s)Completed: 1 0/05/22We11ID#GMW-2 1 ft. 24 ft. Red/brown clay with silt
24 ft- 30 fa Light bmwri,clay_with sand
5a.Well Location:
Former J.M. Daniel Grocery 00-0-0000000233 ft. ft.
Facility/Owner Name Facility ID#(if applicable) t_ LL
ft. ft.
2226 NC Highway 4, Littleton, NC ft. ft. Ll<;
Physical Address,City,and Zip
21.REMARKS
Halifax 0700853
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in de ees/minutes/seconds or decimal degrees:
g � � 22.reftificr,ton:
(if well field,one lat/long is sufficient)
36.392259 N 77.9000065 W `ter 11/08/2022
Signature of Ceititied 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 1 SA 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 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
S.Number of wells constructed: 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 fist all depths ifdijjerent(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,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:.3.25 (in.) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
Hollow stem au 24aabove, also submit a copy of this form within 30 days of completion of well
12.Well construction method: 9er 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