GW1-2022-00307_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.WATER ZONES.", •_ 2
Matt Steele FROM TO DESCRIPTION
Well Contractor Name ft. ft
4548 A ft. ft
NC Well Contractor Certification Number 15.OUTER CASING(for multi-eased:wells OR LINER ifa licable
FROM TO DIAMETER i THICKINESS MATERIAL
Geological Resources, Inc. ft. ft. in
Company Name 16..INNER CASING OR TUBING(geothermal closed-loop)
WM-0601193 FROM I TO I DIAMETER I THICKNESS I MATERIAL
2.Well Construction Permit#: 0 ft. 2 ft. 2" �• sch 40 PVC
List all applicable well permits(i.e.County,State,Parlance,Injection,etc.) ft. I ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL y
❑Agricultural ❑Municipal/Public 2 ft. 12 % 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 TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 % 0.5 fL Grout pour
Non-Water Supply Well:
0.5 ft- 1 ft Bentonite pour
©Monitoring ❑Recovery
Injection Well: ft. ft. r
[]Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier
FROM TO MATERIAL EMPLACEMENT METHOD
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 DESCRIPTION color,hardnes soilfrock type size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 % 0.40 ft. Asphalt
4.Date Weil(s)Completed: Well ID#.
10/25/2022 MW-7 ' 0.40 ft- 2 ft. Tan course sand
2 ft. 8 ft. Gray fine sand
5a.Well Location: 8 f° 12 ft. Tan fine sand
JECO (J&J Texaco) 00-0-0000019342 ft. ft. _
Facility/Owner Name Facility ID#(if applicable)
% ft.
610 Union Chapel Road Pembroke,.NC
> rr. rt j
Physical Address,City,and Zip
Zl.REMARKS _ ,•.
Robeson 9344-4037-4400 DEC 2 2 ' OL
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/(ong is sufficient) :L•Ce tlCati n:
34.686412 N 79.185758 'w = 11/02/2022 -
Signature of Cetified Well Conuact Date
6.Is(are)the well(s): ❑Permanent or 12Temporary 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.
Ifthis 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 r
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 diifferent(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, t:
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter 6 (in.) 24b.For Injection Wells ONLY: In:addition to sending the form to the address in
Solid fli ht auryer" "F 24aabove, also submit a copy of this form within 30 days of completion of well
12.Well construction method: g 7 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
24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test: 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