GW1-2022-00314_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 TONE5' DESCRWnON
Well Contractor Name ft. ft
4548 A ft ft
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if applicable)
FROM TO DIAMETER THICKNESS MATERL&L
Geological Resources, Inc. ft ft
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
WM-0601193 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Constriction 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 I TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 2 ft 12 ft' 2 in' 0.010 sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. I % in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hri ation 0 ft. 0.5 ft 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
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 1 ft. 12 ft Sand ft. ft
'
❑Aquifer Test ❑Stormwater Drainage
�
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillrock 'n size,ete
❑Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) 0 ft 0.40 ft Asphalt
4.Date Weil(s)Completed: Well ID#
10/25/2022 MW-11 0.40 ft 3 ft Tan course sand
3 ft 9 ft. Brown fine sand
5a.Well Location:
JECO (J&J Texaco) 00-0-0000019342 9 ft.ft. 12 ft Red fine sandy clay
ft
Facility/Owner Name - Facility ID#(ifapplicable) t,-p ;•.A v
610 Union Chapel Road, Pembroke, NC ft. ft
t , .• �; aT
Physical Address,City,and Zip 21.REMARKS -71172
Robeson - 9344-4037-4400
County Parcel Identification No.(PIN) �;� r
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 27;ier(cation:
(if well field,one•lat/long is sufficient) •^
34.686412 N 79.185758 11/02/2022
Signature of Certified Well _.�r 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 ISANCAC 02C.0100 or/SANCAC 02C.0200 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#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
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,
If water 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 au er 24aabove, also submit a copy of,this form within 30 days of completion of well
12.Well construction method: 9 g 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
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