GW1-2022-00312_Well Construction - GW1_20221222

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells !!
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1.Well Contractor Information:
Matt Steele 1FaR.MATERZ ONES'TO DESCRIPTION
Well Contractor Name ft. ft. I !
4548 A ft. ft,
NC Well Contractor Certification Number 15.OUTER CASING for multi cased'welIs OR LINER if a icable
FROM I TO I THICKNESSF MATERIAL
Geological Resources, Inc. ft. ft. in.
Company Name FROM TO DIAMETE closed-loo _
16.INNER CASING OR TUBING(geothermal
WM-0601193 RTHICKNESS MATERML
2.Well Construction Permit#: 0 ft' 2 ft- 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 MATERLII
❑Agricultural ❑Municipal/Public 2 fL 12 ft' 2 in. 0.010 sch 40 PVC
[]Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fL ft. in.
❑lndustriallCommercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT MEMOD&AMOUNT
❑Irri ation 0 ft. 0.5 ft- Grout pour
Non-Water Supply Well:
2Monitoring ❑Recovery 0.5 It. 1 ft- Bentonite pour
Injection Well: % ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a lieablo
FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
1 fa 12 a Sand
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20:DRILLING LOG;attach additionnitsheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,sodfrock type in size,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 0.6 ft ! Concrete
10/26/2022 MW-19 0.6 ft- 3 ft. Brown silt
4.Date Well(s)Completed: Well ID#
3 ft. 9 ft. Brown fine sand
5a.Well Location: g ft 12 ft. Tan fine sand
JECO (J&J Texaco) 00-0-0000019342 ft. ft.
Facility/Owner Name Facility ID#(if applicable)
610 Union Chapel Road, Pembroke, NC ft ft. �
fG fG ago z r
Physical Address,City,and Zip 21.REMARKS
Robeson 9344-4037-4400
County Parcel Identification No.(PIN) i i,QF5 zsF : :1.i'i ';n;; .� U^i
nt:lr �^sn
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: Cc a�a u
(if well field,one lat/long is sufficient) ,/' ad
34.686412. lv 79.185758 11/02/2022
Signature of Certified Well Contractor 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 15.4 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 ofthis record has been provided to the well owner.
Ifthis is a repair,fill out known well construction information and explain the nature ofthe
repair under#21 remarks section or on the back ofthisform. 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 oneform. SUBMITTAL INSTUCTIONS
9.Total welll 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 ifelifferent(example-3@200'and 2@100) construction to the following:
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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- 6 (in.) 24b.For Iniection Wells ONLY: Inl addition to sending the form to the address in
Solid fliryht auger 24aabove, also submit a copy of this form within 30 days of completion of well
12.Well construction method: y 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 Ci nler,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test:
24c.For Water Supply&Injection Wells:
Also submit one copy of this form Iwithin 30 days of completion of
131b.Disinfection type: Amount: well construction to the county heial i department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013