GW1-2022-00313_Well Construction - GW1_20221222

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This foam can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES
Matt Steele FROM TO -DESCRIP'I7oN
Well Contractor Name It. ft.
4548 A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING formulti-cased.wells OR LINER if a licable
FROM TO DIAMETER' 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 ft. 2 ft. 2" � 1D- sch 40 PVC
List all applicable well permits(I.e.County,State,Variance,Injection,etc.) ft I 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.
01ndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hri ation 0 1 0.5 IL Grout pour
Non-Water Supply Well:
0.5 ft 1 ft Bentonite pour
©Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑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 DESCRIMON color,hardness,soillrock type,grain size etc
[]Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 0.40 ft. Asphalt
4.Date Well(s)Completed:
10/25/2022 Well ID#MW-9 0.40 ft- 3 ft. Tan course sand
3 ft. 9 fA Brown fine sand
5a.Well Location: 9 fl. 12 ft. Red fine sand
JECO (J&J Texaco) 00-0-0000019342 fL ft.
Facility/Owner Name Facility M#(if applicable) ft. ft
610 Union Chapel Road, Pembroke, NC ft. ft. �"
Physical Address,City,and Zip
21.REMARKS C
Robeson 9344-4037-4400
County Parcel Identification No.(PIN)
� ern!^e r•
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.•�ee�hf ation
(if well field,one lat/long is sufficient)
34.686412 N 79.185758 W 11/02/2022
Signature of Certified Well Con .wr Date
6.Is(are)the well(s): ❑Permanent or I;aTemporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 01C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or FINo 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#11 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: 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 a200'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: 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 g auryer 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
136.Disinfection type: Amount: well construction to the county heal i department of the county where
constructed.
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Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013