GW1-2022-00320_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:
ZO
Matt Steele FROM TONES DESCRIPTION
Well Contractor Name ft. fL
4548 A ft fL
NC Well Contractor Certification Number 15.OUTER CASING for mu1H cased wells OR LINER if a licable
FROM TO DIAMETER• THICKNESS MATERIAL
Geological Resources, Inc. ft. %
Company Name 16.INNER CASING OR TUBING(geothermal closed400
WM-0601193 FROM I TO I DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 2 it. 2" i°' 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 a `.
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICIINESS MATERIAL
❑Agricultural ❑Municipal/Public 2 ft 12 ft. 2 tn' 1 0.010 sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT _
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hri anon 0 ft' 0.5 ft- Grout pour
Non-Water Supply Well:
@Monitoring ❑Recovery 0.5 ft 1 ft Bentonite pour
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier MATERIAL EMPLACEMENT METHOD
FROM TO
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 type,grain sire,eta
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 It- 0.8 ft. Concrete
10/27/2022 MW-21 0•8 ft. 4 ft Brown silt
4.Date Well(s)Completed: Well ID#
4 ft. g fr. 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) •,1
ft. ft
610 Union Chapel Road, Pembroke, NC ft. ft. DFC 2
Physical Address,City,and Zip q1,REMARKS
Robeson 9344-4037-4400 lni'c : _:i PI;
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: rf
22.
(if well field,one tattlong is sufficient) t stnfiCe: n:
34.686412 N 79.185758 W 11/02/2022
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ❑Permanent or QTemporary By signing this form,I hereby cerufy' that the wells)was(were)constructed in accordance
with I5A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or EINo 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 ifelifferent(example-3@200'and 2@100D 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 27699-1617
II
11.Borehole diameter: 6 (in.) 24b.For Infection Wells ONLY:i 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 fothi rm wi n 30 days of completion of
136.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 Resi urces Revised August 2013