GW1-2023-01743_Well Construction - GW1_20230213

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Justin Radford F4.WATER ZONES
FROM TO DESCRH'TTON
Well Contractor Name
ft. ft.
3270 A ft. ft.
NC Well Contractor Certification Number 15.OUTER
CASING
FROM CAS ING(for mMaETEwells OR acable
R S MA ERIAL
Geological Resources, Inc. ft ft in.
Company Name 16.INNER CASING OR TUBING Ueothermal closed-too
FROM TO I DIAMETER I THICKNESS I MATERIAL
2.Well Construction Permit#: 0 ft' 2 ft 2" In' 1 Soh 40 1 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 ❑MunicipaVPublic 2 ft. 12 tt. 2 in. 0.010 sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 0.6 ft. Grout Pour
Non-Water Supply Well:
RMonitoring ❑Recovery 0.6 It 1 tL 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 1 ft. 12 ft. Sand
❑Aquifer Test ❑Stormwater Drainage
tt. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardans,willrock type,grain sim,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft .6 ft. Asphalt
4.Date Well(s)Completed: Well ID#
01/26/2023 MW-19 0.6 ft. 5 ft. Tan backfill sand
5 fL 12 h- DPT; no recovery
5a.Well Location:
ft. ft.
JP Davenport N/A IL M
Facility/Owner Name Facility m#(if applicable)
ft. ft.
5961 Highway 264, Greenville, NC fL ft. L
Physical Address,City,and Zip 21 REMARKS
Pitt 5628-77-5114
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification
(if well field,one lavlong is sufficient)
35.624490 N 77.225604 W 27 Z 3
Signature of Ce d Well Contractor Date
6.is(are)the weB(s): ©Permanent 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 END copy ofthis 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
S.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 AB Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(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: 3.25 (in.) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
Direct r�u$h 24aabove, also submit a copy of this form within 30 days of completion of well
12.Well construction method: p 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