GW1-2023-01695_Well Construction - GW1_20230214

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Matt Steele 14.FR TE
MAft. ft
TO S DESCRIPTION
Well Contractor Name '� } ft
4548-A �..Ar ft. ft.
NC Well Contractor Certification Number FEB 1 2023 15.OUTER CASING for multi-cased wells OR LINER if a lieable
FROM TO DIAMETER THICKNESS MATERIAL
Geological Resources, Inc. ;�;. .; - .n.,1'r;`. ft. ft. in,
Company Name t,`,• '11Q_1i1 1L' 16.INNER CASING OR TUBING.. eothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft' 3 ft. 4 in. Sch 40 PVC
List all applicable well permits(1.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.
1°
❑Agricultural ❑Municipal/Public 3 ft. 18 it• 4 ' 0.010 Sch 40 PVC
[]Geothermal(Heating/Cooling Supply) El Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hri ation 0 ft. 1 ft- Grout Pour
Non-Water Supply Well:
❑Monitoring gRecovery 1 ft 2 ft. Bentonite Pour
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 2 ft' 18 ft #2 Sand Pour
❑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 softeck type size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft, 0.4 ft. Asphalt
4.Date Well(s)Completed: 1 0/3/22 well ID#RW-2 0.4 ft. 3 ft. Red sandy clay
3 ft 12 ft. Tan fine sand
5a.Well Location: 12 ft- 18 ft. Tan fine sand
New Dixie Mart #226 0-034646 ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
4917 Raleigh Road Parkway West, Wilson 28364 ft. ft.
Physical Address,City,and Zip 21.REMARKS
Wilson 2793-73-2703 Soil becomes saturated around 12'.
County Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
35.7619960 N 77.9985590 `y 1/11/23
Signature of Certified Well Contractor; Date
6.Is(are)the well(s): 211'ermanent or ❑Temporary 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 ONo copy of this record has been provided 10 the well owner.
Ifthis is a repair,fill out known well construction information and explain the nature of the
repair under 921 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: 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: 18 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(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,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection Wells ONLY: �In addition to sending the form to the address in
6" Solid F I i tit Au a rs 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: g 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 or water Resources Revised August 2013