GW1-2022-00304_Well Construction - GW1_20221222

WELL CONSTRUCTION RECORD For Internal Use ONLY: '
This form can be used for single or multiple wells
1.Well Contractor Information:
14.Matt Steele FROM WATER ZONES DESCRIPTION
Well Contractor Name ft. ft.
4548 A ft ft
NC Well Contractor Certification Number 15.OUTER CASING,for multltased wells OR LINER if applicable)
FROM TO DIAMETER THICKNESS MATERIAI. '
Geological Resources, Inc. ft ft in.
Company Name 16.INNER CASING OR TUBING. eothermal closed-loop)
WM-0601193 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. TO
it 2" i"• sch 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 TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 2 ft 12 il' 2 in. 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 I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Itri ation 0 ft. 0.5 fL Grout . pour
Non-Water Supply Well:
RMonitoring ❑Recovery 0.5 ft 1 fQ Bentonite pour
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 1 ft' 12 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 DESCRHMON color,hardness,soil/rock type rain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 0.40 ft Asphalt
4.Date Weil(s)Completed:
10/25/2022 Well ID#MW-5 0.40 ft 3 ft Tan course sand
3 ft. 7 ft Gray fine sand
5a.Well Location:
JECO (J&J Texaco) 00-0-0000019342 7 ft. 12 ft Tan fine sand
Facility/Owner Name Facility ID#(ifapplicable) ft ft `a�n r} �...'
ft. ft. ti 0- .,s a V Dt...,i;
610 Union Chapel Road, Pembroke, NC ft. ft DEC 2 2 7022
Physical Address,City,and Zip 21 REMARKS
Robeson 9344-4037-4400 ;n;;i. ;,t� , 'r .�.;.;- un
County Parcel Identification No.(PIN) L;"a Ui 6' U
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: �
(if well field,one lat/long is sufficient) �2 Ce 'r Acati e
34.686412 N 79.185758 11/02/2022
Signature of Certified Well Contrnetor Date
6.Is(are)the well(s): ❑Permanent or IOTemporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 15.4 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 some construction,you can
submit one form. 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 it different(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 flight auger 24aabove, also submit a copy of,this form within 30 days of completion of well
12.Well construction method: Solid 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 C enter,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 heal i department of the county where
constructed. 1.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013