GW1--06410_Well Construction - GW1_20231009

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This fonn can be used for single or multiple wells
1.Well Contractor Information: ,
Kevin White 14.WATERZONES
FROM TO , DESCRIPTION
Well Contractor Name ft. ft. !
2973 ft ft. I i
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM ft. TO ft. DIAMETER in. THICKNESS MATERIAL
Parratt-Wolff, Inc. i
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 5 ft. 2 in' sch40 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 5 ft. 20 it 2 1O' 010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
FROM TO - MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft 2 it Portland Cem Pour
• Non-Water Supply Well:
OMonitoring ❑Recovery 2 ft 4 it Bentonite Chii Pour
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable) '
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
4 it 20 ft #1 Sand Tremie
❑Aquifer Test ❑StormwaterDrainage 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#2I Remarks) ft ft
ft. ft.
4.Date Well(s)Completed: 8-15-23 Well ID# SB-13
ft ft.
Sa.Well Location: ft. ft. -"
Chevron 115077-Chic-fila ft. ft. OCT 0 Z0Z3
Facility/Owner Name Facility ID#(if applicable) —-- i - -
ft ft. Infer...-.::!an P,- ^r
3400 N Elm Street, Lumberton 28358 '' '" '''`'t I""
ft ft. U .:n1.:I.OG
Physical Address,City,and Zip- 21.,REMARKS
Robeson • 939274709800 1 Bottom Cap
County Parcel Identification No.(PIN) '1 J-Plug
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: '
(if well field,one lat/long is sufficient)
34.640900 N -79.007284 Nn Ittie�i t �_\�& q, ( , -.).3
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with/.5.4 NCAC 02C.0100 or ISA 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-2I remarks section or on the hack 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 some construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 20 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if diffierent(example-3 a 200'and 2 a 100') construction to the following: I '
10.Static water level below top of casing: unknown (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: 4 (in.) 24b. For Injection Wells ONLY In addition to sending the form to the address in
HSA/ DT-22 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) I I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test:
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-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013