GW1-2022-00310_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
Matt Steele FROM TO DESCRIPTION
Well Contractor Name ft.
4548 A fL %
NC Well Contractor Certification Number 15.OUTER CASING,for multi-cased wells OR LINER if applicable)
FROM TO DIAMETER l THICKNESS MATERIAL
Geological Resources, Inc. ft. ft in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
WM-0601193 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 IL 2 IL 2" in. 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 fL 12 ft' 2 in'' 0.010 sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. it in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) FR GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 0.5 fL Grout ; pour
Non-Water Supply Well:
©Monitoring ❑Recovery 0.5 ft 1 fa 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 DESCRIPTION color,hardness soiltrock e n size,eta
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 0.40 fL Asphalt
4.Date Well(s)Completed: 1 0/25/2022Well ID#MW-13 0.40 ft- 4 fa Brown sandy clay
4 ft. 9 ft. Brown fine sand
5a.Well Location: 9 IL 12 fL Tan fine sand
JECO (J&J Texaco) 00-0-0000019342
Facility/Owner Name Facility ID#(if applicable) ft
rFs
610 Union Chapel Road, Pembroke, NC ft. ft.
Physical Address,City,and`Zip 21.REMARKS ` r_
Robeson 9344-4037-4400 ur
,L3a"']1 ?i: .,-yd<a:iSJ
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: Ccati�
(if well field,one lat/long is sufficient) �,34.686412 N 79.185758 w 11/02/2022
Signature of Certified Well Con cto Date
6.Is(are)the well(s): ❑Permanent or I;zTemporary 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 ©No copy ofthis 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 pagei 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: 12 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(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 276994617
11.Borehole diameter: 6 (in.) 24b.For Inlection Wells ONLY: In addition to sending the form to the address in
Solid fli ht 24aabove, also submit a copy of this form within 30 days of completion of well
12.Well construction method: 9 au er 9 construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) I
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 Iwithin 30 days of completion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed. }I
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013