GW1-2022-00316_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:
Matt Steele 1F4ROWATER ZONES M TO I DESCRIPTION
Well Contractor Name ft. ft
4548 A ft ft
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if'a icable
FROM TO DIAMETER THICKNESSI MATERIAL
Geological Resources, Inc. ft I % , in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
WM-0601220 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft• 2 ft. 2" sch 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 % 12 ft. 2 'n' 0.010 sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft.
❑Industrial/Commercial El Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hri ation 0 ft' 0.5 fL Grout ' pour
Non-Water Supply Well:,
0.5 ft' 1 ft Bentonite pour
IDMonitoring ❑Recovery
Injection Well: 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,soil/rock type,grain size,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft ft. Brown silt
10/26/2022 MW-15 4 ft. g ft. Brown fine sand
4.Date Well(s)Completed: Well ID#
9 ft- 12 ft; Tan fine sand
5a.Well Location: ft. fL
JECO (J&J Texaco) 00-0-0000019342 ft. ft. _
Facility/Owner Name Facility ID#(if applicable) ft ft 4. (^
610 Union Chapel Road, Pembroke, NC ft. �`s"
fL
Physical Address,City,and Zip
21.REMARKS _ .d
Robeson 9344-4037-4400
County Parcel Identification No.(PIN)
ratrF�•s �,
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: "ice catio
(if well field,one lat/long is sufficient) �.
34.686412 N 79.185758 W _ 11/02/2022
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ❑Permanent or RTemporary 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 l!JNo 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 farm. 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 ONLYwith 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:I form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@I00) construction to the following:
I
10.Static water level below top of casing: n/a (ft.) Division of Water Resourl es,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 au er 24aabove, also submit a copy of'this form within 30 days of completion of well
12.Well construction method: 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 he'lth department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013