HomeMy WebLinkAboutRA-8268_46344_CA_RPTS_20200423_CSAwell logsGeological Resources, Inc.Phone:(704) 845-4010
3502 Hayes Road Fax:(704) 845-4012
Monroe, NC 28110
SUBSURFACE LOG
Project New Dixie Mart #226
Address 4917 Raleigh Road Parkway West, Wilson, NC
Boring Number MW-1 Date Drilled
Sample Method NA Drilling Method
Completion Details
Driller Justin Radford (NC Cert #3270-A)Log By Ethan Rogerson
Lab Sample OVA
Depth Sample Interval(ft)ppm LITHOLOGY
0 0' - 1' Gravel
2
4
6
8
10
12
14
16
18
20
22
24
26
28
30
Well set at 20'
13' - 20' Tan coarse sand (wet)
07/26/2018
4.25" Rotary Auger
2" PVC SCH 40 (0.010) Slotted Screen 10-20', 2" PVC riser 0-10'
1' - 13' Tan medium sand
Geological Resources, Inc.Phone:(704) 845-4010
3502 Hayes Road Fax:(704) 845-4012
Monroe, NC 28110
SUBSURFACE LOG
Project New Dixie Mart #226
Address 4917 Raleigh Road Parkway West, Wilson, NC
Boring Number MW-2 Date Drilled
Sample Method Drilling Method
Completion Details
Driller Sammy Bowers (NC Cert #3220)Log By Ethan Rogerson
Lab Sample OVA
Depth Sample Interval(ft)ppm LITHOLOGY
0 0' - 0.5' Asphalt
2
4
6
8
10
12
14
16
18 Well set at 18'
20
22
24
26
28
30
03/06/2019
6" Rotary Auger
2" PVC SCH 40 (0.010) Slotted Screen 3-18', 2" PVC riser 0-3'
0.5' - 1' Brown sand
1' - 7' Orange clay/sand
7' - 18' White clay/sand
WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
Form GW-1 North Carolina Department of Environment and Natural Resources – Division of Water Resources Revised August 2013
1. Well Contractor Information:
Well Contractor Name
NC Well Contractor Certification Number
Company Name 2. Well Construction Permit #:
List all applicable well permits (i.e. County, State, Variance, Injection, etc.)
3. Well Use (check well use): Water Supply Well: □Agricultural □Municipal/Public □Geothermal (Heating/Cooling Supply) □Residential Water Supply (single)
□Industrial/Commercial □Residential Water Supply (shared) □Irrigation
Non-Water Supply Well: □Monitoring □Recovery
Injection Well: □Aquifer Recharge □Groundwater Remediation
□Aquifer Storage and Recovery □Salinity Barrier □Aquifer Test □Stormwater Drainage
□Experimental Technology □Subsidence Control
□Geothermal (Closed Loop) □Tracer □Geothermal (Heating/Cooling Return) □Other (explain under #21 Remarks)
4. Date Well(s) Completed: ____________ Well ID#______________________ 5a. Well Location:
Facility/Owner Name Facility ID# (if applicable)
Physical Address, City, and Zip
County Parcel Identification No. (PIN) 5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees: (if well field, one lat/long is sufficient) N W
6. Is (are) the well(s): □Permanent or □Temporary
7. Is this a repair to an existing well: □Yes or □No
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.
8. Number of wells constructed:
For multiple injection or non-water supply wells ONLY with the same construction, you can
submit one form.
9. Total well depth below land surface: (ft.)
For multiple wells list all depths if different (example- 3@200’ and 2@100′)
10. Static water level below top of casing: (ft.)
If water level is above casing, use “+”
11. Borehole diameter: (in.) 12. Well construction method: (i.e. auger, rotary, cable, direct push, etc.) FOR WATER SUPPLY WELLS ONLY: 13a. Yield (gpm) Method of test: 13b. Disinfection type: Amount:
14. WATER ZONES FROM TO DESCRIPTION
ft. ft.
ft. ft.
15. OUTER CASING (for multi-cased wells) OR LINER (if applicable) FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
16. INNER CASING OR TUBING (geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
ft. ft. in.
17. SCREEN FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
ft. ft. in.
18. GROUT
FROM TO MATERIAL EMPLACEMENT METHOD & AMOUNT
ft. ft.
ft. ft.
ft. ft.
19. SAND/GRAVEL PACK (if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
ft. ft.
20. DRILLING LOG (attach additional sheets if necessary) FROM TO DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
ft. ft.
ft. ft.
ft. ft.
ft. ft.
ft. ft.
ft. ft.
ft. ft.
21. REMARKS
22. Certification:
Signature of Certified Well Contractor Date
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
copy of this record has been provided to the well owner.
23. Site diagram or additional well details: You may use the back of this page to provide additional well site details or well construction details. You may also attach additional pages if necessary. SUBMITTAL INSTUCTIONS 24a. For All Wells: Submit this form within 30 days of completion of well construction to the following: Division of Water Resources, Information Processing Unit, 1617 Mail Service Center, Raleigh, NC 27699-1617 24b. For Injection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well construction to the following: Division of Water Resources, Underground Injection Control Program, 1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion ofwell construction to the county health department of the county whereconstructed.
For Internal Use ONLY:
Sammy Bowers
3220
Geological Resources, Inc.
N/A
03/6/19 MW-2
New Dixie #226 0-0000034646
4917 Raleigh Road Parkway West, Wilson, 27839
Wilson 2793-73-2703
35.695670 77.825220
1
18
6.48
6
auger
0 3 2 sch 40 PVC
3 18 2 0.010 sch 40 PVC
0 1 grout pour
1 2 bentonite pour
2 18 #2 sand pour
0 0.5 Asphalt
0.5 1 Brown sand
1 7 Orange clay/sand
7 18 White clay/sand
04/09/19
Geological Resources, Inc.Phone:(704) 845-4010
3502 Hayes Road Fax:(704) 845-4012
Monroe, NC 28110
SUBSURFACE LOG
Project New Dixie Mart #226
Address 4917 Raleigh Road Parkway West, Wilson, NC
Boring Number MW-3 Date Drilled
Sample Method Drilling Method
Completion Details
Driller Sammy Bowers (NC Cert #3220)Log By Ethan Rogerson
Lab Sample OVA
Depth Sample Interval(ft)ppm LITHOLOGY
0 0' - 0.5' Asphalt
2
4
6
8
10
12
14
16
18 Well set at 18'
20
22
24
26
28
30
12' - 18' Light brown clay (wet)
03/06/2019
6" Rotary Auger
2" PVC SCH 40 (0.010) Slotted Screen 3-18', 2" PVC riser 0-3'
0.5' - 1' Brown sand
1' - 7' Orange clay/sand (wet at 6')
7' - 12' White clay/sand (wet)
WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
Form GW-1 North Carolina Department of Environment and Natural Resources – Division of Water Resources Revised August 2013
1. Well Contractor Information:
Well Contractor Name
NC Well Contractor Certification Number
Company Name 2. Well Construction Permit #:
List all applicable well permits (i.e. County, State, Variance, Injection, etc.)
3. Well Use (check well use): Water Supply Well: □Agricultural □Municipal/Public □Geothermal (Heating/Cooling Supply) □Residential Water Supply (single)
□Industrial/Commercial □Residential Water Supply (shared) □Irrigation
Non-Water Supply Well: □Monitoring □Recovery
Injection Well: □Aquifer Recharge □Groundwater Remediation
□Aquifer Storage and Recovery □Salinity Barrier □Aquifer Test □Stormwater Drainage
□Experimental Technology □Subsidence Control
□Geothermal (Closed Loop) □Tracer □Geothermal (Heating/Cooling Return) □Other (explain under #21 Remarks)
4. Date Well(s) Completed: ____________ Well ID#______________________ 5a. Well Location:
Facility/Owner Name Facility ID# (if applicable)
Physical Address, City, and Zip
County Parcel Identification No. (PIN) 5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees: (if well field, one lat/long is sufficient) N W
6. Is (are) the well(s): □Permanent or □Temporary
7. Is this a repair to an existing well: □Yes or □No
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.
8. Number of wells constructed:
For multiple injection or non-water supply wells ONLY with the same construction, you can
submit one form.
9. Total well depth below land surface: (ft.)
For multiple wells list all depths if different (example- 3@200’ and 2@100′)
10. Static water level below top of casing: (ft.)
If water level is above casing, use “+”
11. Borehole diameter: (in.) 12. Well construction method: (i.e. auger, rotary, cable, direct push, etc.) FOR WATER SUPPLY WELLS ONLY: 13a. Yield (gpm) Method of test: 13b. Disinfection type: Amount:
14. WATER ZONES FROM TO DESCRIPTION
ft. ft.
ft. ft.
15. OUTER CASING (for multi-cased wells) OR LINER (if applicable) FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
16. INNER CASING OR TUBING (geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
ft. ft. in.
17. SCREEN FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
ft. ft. in.
18. GROUT
FROM TO MATERIAL EMPLACEMENT METHOD & AMOUNT
ft. ft.
ft. ft.
ft. ft.
19. SAND/GRAVEL PACK (if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
ft. ft.
20. DRILLING LOG (attach additional sheets if necessary) FROM TO DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
ft. ft.
ft. ft.
ft. ft.
ft. ft.
ft. ft.
ft. ft.
ft. ft.
21. REMARKS
22. Certification:
Signature of Certified Well Contractor Date
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
copy of this record has been provided to the well owner.
23. Site diagram or additional well details: You may use the back of this page to provide additional well site details or well construction details. You may also attach additional pages if necessary. SUBMITTAL INSTUCTIONS 24a. For All Wells: Submit this form within 30 days of completion of well construction to the following: Division of Water Resources, Information Processing Unit, 1617 Mail Service Center, Raleigh, NC 27699-1617 24b. For Injection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well construction to the following: Division of Water Resources, Underground Injection Control Program, 1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion ofwell construction to the county health department of the county whereconstructed.
For Internal Use ONLY:
Sammy Bowers
3220
Geological Resources, Inc.
N/A
03/6/19 MW-3
New Dixie #226 0-0000034646
4917 Raleigh Road Parkway West, Wilson, 27839
Wilson 2793-73-2703
35.695670 77.825220
1
18
3.98
6
auger
0 3 2 sch 40 PVC
3 18 2 0.010 sch 40 PVC
0 1 grout pour
1 2 bentonite pour
2 18 #2 sand pour
0 0.5 Asphalt
0.5 1 Brown sand
1 7 Orange clay/sand (wet)
7 12 White clay/sand (wet)
12 18 Light brown clay (wet)
04/09/19
Geological Resources, Inc.Phone:(704) 845-4010
3502 Hayes Road Fax:(704) 845-4012
Monroe, NC 28110
SUBSURFACE LOG
Project New Dixie Mart #226
Address 4917 Raleigh Road Parkway West, Wilson, NC
Boring Number MW-4 Date Drilled
Sample Method Drilling Method
Completion Details
Driller Sammy Bowers (NC Cert #3220)Log By Ethan Rogerson
Lab Sample OVA
Depth Sample Interval(ft)ppm LITHOLOGY
0 0' - 1.5' Brown sand
2
4
6
8
10
12
14
16
18 Well set at 18'
20
22
24
26
28
30
03/06/2019
6" Rotary Auger
2" PVC SCH 40 (0.010) Slotted Screen 3-18', 2" PVC riser 0-3'
1.5 ' -6' Orange clay/sand
6' - 18' Light brown clay (wet at 6')
WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
Form GW-1 North Carolina Department of Environment and Natural Resources – Division of Water Resources Revised August 2013
1. Well Contractor Information:
Well Contractor Name
NC Well Contractor Certification Number
Company Name 2. Well Construction Permit #:
List all applicable well permits (i.e. County, State, Variance, Injection, etc.)
3. Well Use (check well use): Water Supply Well: □Agricultural □Municipal/Public □Geothermal (Heating/Cooling Supply) □Residential Water Supply (single)
□Industrial/Commercial □Residential Water Supply (shared) □Irrigation
Non-Water Supply Well: □Monitoring □Recovery
Injection Well: □Aquifer Recharge □Groundwater Remediation
□Aquifer Storage and Recovery □Salinity Barrier □Aquifer Test □Stormwater Drainage
□Experimental Technology □Subsidence Control
□Geothermal (Closed Loop) □Tracer □Geothermal (Heating/Cooling Return) □Other (explain under #21 Remarks)
4. Date Well(s) Completed: ____________ Well ID#______________________ 5a. Well Location:
Facility/Owner Name Facility ID# (if applicable)
Physical Address, City, and Zip
County Parcel Identification No. (PIN) 5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees: (if well field, one lat/long is sufficient) N W
6. Is (are) the well(s): □Permanent or □Temporary
7. Is this a repair to an existing well: □Yes or □No
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.
8. Number of wells constructed:
For multiple injection or non-water supply wells ONLY with the same construction, you can
submit one form.
9. Total well depth below land surface: (ft.)
For multiple wells list all depths if different (example- 3@200’ and 2@100′)
10. Static water level below top of casing: (ft.)
If water level is above casing, use “+”
11. Borehole diameter: (in.) 12. Well construction method: (i.e. auger, rotary, cable, direct push, etc.) FOR WATER SUPPLY WELLS ONLY: 13a. Yield (gpm) Method of test: 13b. Disinfection type: Amount:
14. WATER ZONES FROM TO DESCRIPTION
ft. ft.
ft. ft.
15. OUTER CASING (for multi-cased wells) OR LINER (if applicable) FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
16. INNER CASING OR TUBING (geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
ft. ft. in.
17. SCREEN FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
ft. ft. in.
18. GROUT
FROM TO MATERIAL EMPLACEMENT METHOD & AMOUNT
ft. ft.
ft. ft.
ft. ft.
19. SAND/GRAVEL PACK (if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
ft. ft.
20. DRILLING LOG (attach additional sheets if necessary) FROM TO DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
ft. ft.
ft. ft.
ft. ft.
ft. ft.
ft. ft.
ft. ft.
ft. ft.
21. REMARKS
22. Certification:
Signature of Certified Well Contractor Date
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
copy of this record has been provided to the well owner.
23. Site diagram or additional well details: You may use the back of this page to provide additional well site details or well construction details. You may also attach additional pages if necessary. SUBMITTAL INSTUCTIONS 24a. For All Wells: Submit this form within 30 days of completion of well construction to the following: Division of Water Resources, Information Processing Unit, 1617 Mail Service Center, Raleigh, NC 27699-1617 24b. For Injection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well construction to the following: Division of Water Resources, Underground Injection Control Program, 1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion ofwell construction to the county health department of the county whereconstructed.
For Internal Use ONLY:
Sammy Bowers
3220
Geological Resources, Inc.
N/A
03/6/19 MW-4
New Dixie #226 0-0000034646
4917 Raleigh Road Parkway West, Wilson, 27839
Wilson 2793-73-2703
35.695670 77.825220
1
18
3.97
6
auger
0 3 2 sch 40 PVC
3 18 2 0.010 sch 40 PVC
0 1 grout pour
1 2 bentonite pour
2 18 #2 sand pour
0 1.5 Brown sand
1.5 6 Orange clay/sand
6 18 Light brown clay (wet)
04/09/19
Geological Resources, Inc.Phone:(704) 845-4010
3502 Hayes Road Fax:(704) 845-4012
Monroe, NC 28110
SUBSURFACE LOG
Project New Dixie Mart 226
Address 4917 Raleigh Road Parkway W, Wilson, NC
Boring Number MW-5 Date Drilled
Sample Method Grab Drilling Method Direct Push, 4" OD
Completion DetailsWell installed at completion to a total depth of 18 feet with a 15 foot screened interval
Driller Justin Radford (GRI)Log By Justin Radford (GRI)
Lab Sample OVA
Depth Sample Interval(ft)ppm LITHOLOGY
0
1' - 4' Orange clay
2
4
6
8
10
12
14
16
18
20
22
24
26
28
30
32
34
36
5' - 18' Direct push; no recovery
06/11/19
0' - 1' Brown fine sand
4' - 5' White silt
Well set at 18 feet
WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
Form GW-1 North Carolina Department of Environment and Natural Resources – Division of Water Resources Revised August 2013
1. Well Contractor Information:
Well Contractor Name
NC Well Contractor Certification Number
Company Name 2. Well Construction Permit #:
List all applicable well permits (i.e. County, State, Variance, Injection, etc.)
3. Well Use (check well use): Water Supply Well: □Agricultural □Municipal/Public □Geothermal (Heating/Cooling Supply) □Residential Water Supply (single)
□Industrial/Commercial □Residential Water Supply (shared) □Irrigation
Non-Water Supply Well: □Monitoring □Recovery
Injection Well: □Aquifer Recharge □Groundwater Remediation
□Aquifer Storage and Recovery □Salinity Barrier □Aquifer Test □Stormwater Drainage
□Experimental Technology □Subsidence Control
□Geothermal (Closed Loop) □Tracer □Geothermal (Heating/Cooling Return) □Other (explain under #21 Remarks)
4. Date Well(s) Completed: ____________ Well ID#______________________ 5a. Well Location:
Facility/Owner Name Facility ID# (if applicable)
Physical Address, City, and Zip
County Parcel Identification No. (PIN) 5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees: (if well field, one lat/long is sufficient) N W
6. Is (are) the well(s): □Permanent or □Temporary
7. Is this a repair to an existing well: □Yes or □No
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.
8. Number of wells constructed:
For multiple injection or non-water supply wells ONLY with the same construction, you can
submit one form.
9. Total well depth below land surface: (ft.)
For multiple wells list all depths if different (example- 3@200’ and 2@100′)
10. Static water level below top of casing: (ft.)
If water level is above casing, use “+”
11. Borehole diameter: (in.) 12. Well construction method: (i.e. auger, rotary, cable, direct push, etc.) FOR WATER SUPPLY WELLS ONLY: 13a. Yield (gpm) Method of test: 13b. Disinfection type: Amount:
14. WATER ZONES FROM TO DESCRIPTION
ft. ft.
ft. ft.
15. OUTER CASING (for multi-cased wells) OR LINER (if applicable) FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
16. INNER CASING OR TUBING (geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
ft. ft. in.
17. SCREEN FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
ft. ft. in.
18. GROUT
FROM TO MATERIAL EMPLACEMENT METHOD & AMOUNT
ft. ft.
ft. ft.
ft. ft.
19. SAND/GRAVEL PACK (if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
ft. ft.
20. DRILLING LOG (attach additional sheets if necessary) FROM TO DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
ft. ft.
ft. ft.
ft. ft.
ft. ft.
ft. ft.
ft. ft.
ft. ft.
21. REMARKS
22. Certification:
Signature of Certified Well Contractor Date
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
copy of this record has been provided to the well owner.
23. Site diagram or additional well details: You may use the back of this page to provide additional well site details or well construction details. You may also attach additional pages if necessary. SUBMITTAL INSTUCTIONS 24a. For All Wells: Submit this form within 30 days of completion of well construction to the following: Division of Water Resources, Information Processing Unit, 1617 Mail Service Center, Raleigh, NC 27699-1617 24b. For Injection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well construction to the following: Division of Water Resources, Underground Injection Control Program, 1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion ofwell construction to the county health department of the county whereconstructed.
For Internal Use ONLY:
Justin Radford
3270 A
Geological Resources, Inc.
N/A
06/11/19 MW-5
New Dixie #226 0-0000034646
4917 Raleigh Road Parkway West, Wilson, 27839
Wilson 2793-73-2703
35.695670 77.825220
1
18
6.51
4"
4" Direct push
0 3 2 sch 40 PVC
3 18 2 0.010 sch 40 PVC
0 1 grout pour
1 2 bentonite pour
2 18 #2 sand pour
0 1 Brown fine sand
1 4 Orange clay
4 5 White silt
5 18 Direct push; no lithography
6/14/19
Geological Resources, Inc.Phone:(704) 845-4010
3502 Hayes Road Fax:(704) 845-4012
Monroe, NC 28110
SUBSURFACE LOG
Project New Dixie Mart 226
Address 4917 Raleigh Road Parkway W, Wilson, NC
Boring Number MW-6 Date Drilled
Sample Method Grab Drilling Method Direct Push, 4" OD
Completion DetailsWell installed at completion to a total depth of 18 feet with a 15 foot screened interval
Driller Justin Radford (GRI)Log By Justin Radford (GRI)
Lab Sample OVA
Depth Sample Interval(ft)ppm LITHOLOGY
0
1' - 4' Orange clay
2
4
6
8
10
12
14
16
18
20
22
24
26
28
30
32
34
36
06/11/19
0' - 1' Brown fine sand
4' - 5' White silt
5' - 18' Direct push; no recovery
Well set at 18 feet
WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
Form GW-1 North Carolina Department of Environment and Natural Resources – Division of Water Resources Revised August 2013
1. Well Contractor Information:
Well Contractor Name
NC Well Contractor Certification Number
Company Name 2. Well Construction Permit #:
List all applicable well permits (i.e. County, State, Variance, Injection, etc.)
3. Well Use (check well use): Water Supply Well: □Agricultural □Municipal/Public □Geothermal (Heating/Cooling Supply) □Residential Water Supply (single)
□Industrial/Commercial □Residential Water Supply (shared) □Irrigation
Non-Water Supply Well: □Monitoring □Recovery
Injection Well: □Aquifer Recharge □Groundwater Remediation
□Aquifer Storage and Recovery □Salinity Barrier □Aquifer Test □Stormwater Drainage
□Experimental Technology □Subsidence Control
□Geothermal (Closed Loop) □Tracer □Geothermal (Heating/Cooling Return) □Other (explain under #21 Remarks)
4. Date Well(s) Completed: ____________ Well ID#______________________ 5a. Well Location:
Facility/Owner Name Facility ID# (if applicable)
Physical Address, City, and Zip
County Parcel Identification No. (PIN) 5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees: (if well field, one lat/long is sufficient) N W
6. Is (are) the well(s): □Permanent or □Temporary
7. Is this a repair to an existing well: □Yes or □No
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.
8. Number of wells constructed:
For multiple injection or non-water supply wells ONLY with the same construction, you can
submit one form.
9. Total well depth below land surface: (ft.)
For multiple wells list all depths if different (example- 3@200’ and 2@100′)
10. Static water level below top of casing: (ft.)
If water level is above casing, use “+”
11. Borehole diameter: (in.) 12. Well construction method: (i.e. auger, rotary, cable, direct push, etc.) FOR WATER SUPPLY WELLS ONLY: 13a. Yield (gpm) Method of test: 13b. Disinfection type: Amount:
14. WATER ZONES FROM TO DESCRIPTION
ft. ft.
ft. ft.
15. OUTER CASING (for multi-cased wells) OR LINER (if applicable) FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
16. INNER CASING OR TUBING (geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
ft. ft. in.
17. SCREEN FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
ft. ft. in.
18. GROUT
FROM TO MATERIAL EMPLACEMENT METHOD & AMOUNT
ft. ft.
ft. ft.
ft. ft.
19. SAND/GRAVEL PACK (if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
ft. ft.
20. DRILLING LOG (attach additional sheets if necessary) FROM TO DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
ft. ft.
ft. ft.
ft. ft.
ft. ft.
ft. ft.
ft. ft.
ft. ft.
21. REMARKS
22. Certification:
Signature of Certified Well Contractor Date
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
copy of this record has been provided to the well owner.
23. Site diagram or additional well details: You may use the back of this page to provide additional well site details or well construction details. You may also attach additional pages if necessary. SUBMITTAL INSTUCTIONS 24a. For All Wells: Submit this form within 30 days of completion of well construction to the following: Division of Water Resources, Information Processing Unit, 1617 Mail Service Center, Raleigh, NC 27699-1617 24b. For Injection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well construction to the following: Division of Water Resources, Underground Injection Control Program, 1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion ofwell construction to the county health department of the county whereconstructed.
For Internal Use ONLY:
Justin Radford
3270 A
Geological Resources, Inc.
N/A
06/11/19 MW-6
New Dixie #226 0-0000034646
4917 Raleigh Road Parkway West, Wilson, 27839
Wilson 2793-73-2703
35.695670 77.825220
1
18
9.16
4"
4" Direct push
0 3 2 sch 40 PVC
3 18 2 0.010 sch 40 PVC
0 1 grout pour
1 2 bentonite pour
2 18 #2 sand pour
0 1 Brown fine sand
1 4 Orange clay
4 5 White silt
5 18 Direct push; no lithography
6/14/19
Geological Resources, Inc.Phone:(704) 845-4010
3502 Hayes Road Fax:(704) 845-4012
Monroe, NC 28110
SUBSURFACE LOG
Project New Dixie Mart 226
Address 4917 Raleigh Road Parkway W, Wilson, NC
Boring Number MW-7 Date Drilled
Sample Method Grab Drilling Method Auger, 6" OD
Completion DetailsWell installed at completion to a total depth of 18 feet with a 15 foot screened interval
Driller Justin Radford (GRI)Log By Mike Ellis (GRI)
Lab Sample OVA
Depth Sample Interval(ft)ppm LITHOLOGY
0
0.5' - 4' Orange clay
2
4
6
8
10
12
14
16
18
20
22
24
26
28
30
32
34
36
06/12/19
0 - 0.5' Asphalt
4' - 18' White silt
Well set at 18 feet
WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
Form GW-1 North Carolina Department of Environment and Natural Resources – Division of Water Resources Revised August 2013
1. Well Contractor Information:
Well Contractor Name
NC Well Contractor Certification Number
Company Name 2. Well Construction Permit #:
List all applicable well permits (i.e. County, State, Variance, Injection, etc.)
3. Well Use (check well use): Water Supply Well: □Agricultural □Municipal/Public □Geothermal (Heating/Cooling Supply) □Residential Water Supply (single)
□Industrial/Commercial □Residential Water Supply (shared) □Irrigation
Non-Water Supply Well: □Monitoring □Recovery
Injection Well: □Aquifer Recharge □Groundwater Remediation
□Aquifer Storage and Recovery □Salinity Barrier □Aquifer Test □Stormwater Drainage
□Experimental Technology □Subsidence Control
□Geothermal (Closed Loop) □Tracer □Geothermal (Heating/Cooling Return) □Other (explain under #21 Remarks)
4. Date Well(s) Completed: ____________ Well ID#______________________ 5a. Well Location:
Facility/Owner Name Facility ID# (if applicable)
Physical Address, City, and Zip
County Parcel Identification No. (PIN) 5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees: (if well field, one lat/long is sufficient) N W
6. Is (are) the well(s): □Permanent or □Temporary
7. Is this a repair to an existing well: □Yes or □No
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.
8. Number of wells constructed:
For multiple injection or non-water supply wells ONLY with the same construction, you can
submit one form.
9. Total well depth below land surface: (ft.)
For multiple wells list all depths if different (example- 3@200’ and 2@100′)
10. Static water level below top of casing: (ft.)
If water level is above casing, use “+”
11. Borehole diameter: (in.) 12. Well construction method: (i.e. auger, rotary, cable, direct push, etc.) FOR WATER SUPPLY WELLS ONLY: 13a. Yield (gpm) Method of test: 13b. Disinfection type: Amount:
14. WATER ZONES FROM TO DESCRIPTION
ft. ft.
ft. ft.
15. OUTER CASING (for multi-cased wells) OR LINER (if applicable) FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
16. INNER CASING OR TUBING (geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
ft. ft. in.
17. SCREEN FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
ft. ft. in.
18. GROUT
FROM TO MATERIAL EMPLACEMENT METHOD & AMOUNT
ft. ft.
ft. ft.
ft. ft.
19. SAND/GRAVEL PACK (if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
ft. ft.
20. DRILLING LOG (attach additional sheets if necessary) FROM TO DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
ft. ft.
ft. ft.
ft. ft.
ft. ft.
ft. ft.
ft. ft.
ft. ft.
21. REMARKS
22. Certification:
Signature of Certified Well Contractor Date
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
copy of this record has been provided to the well owner.
23. Site diagram or additional well details: You may use the back of this page to provide additional well site details or well construction details. You may also attach additional pages if necessary. SUBMITTAL INSTUCTIONS 24a. For All Wells: Submit this form within 30 days of completion of well construction to the following: Division of Water Resources, Information Processing Unit, 1617 Mail Service Center, Raleigh, NC 27699-1617 24b. For Injection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well construction to the following: Division of Water Resources, Underground Injection Control Program, 1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion ofwell construction to the county health department of the county whereconstructed.
For Internal Use ONLY:
Justin Radford
3270 A
Geological Resources, Inc.
N/A
06/12/19 MW-7
New Dixie #226 0-0000034646
4917 Raleigh Road Parkway West, Wilson, 27839
Wilson 2793-73-2703
35.695670 77.825220
1
18
10.03
6"
6" OD Augers
0 3 2 sch 40 PVC
3 18 2 0.010 sch 40 PVC
0 1 grout pour
1 2 bentonite pour
2 18 #2 sand pour
0 0.5 Asphalt
0.5 4 Orange clay
4 18 White silt
6/14/19
Geological Resources, Inc.Phone:(704) 845-4010
3502 Hayes Road Fax:(704) 845-4012
Monroe, NC 28110
SUBSURFACE LOG
Project New Dixie Mart 226
Address 4917 Raleigh Road Parkway W, Wilson, NC
Boring Number MW-8 Date Drilled
Sample Method Grab Drilling Method Direct Push, 4" OD
Completion DetailsWell installed at completion to a total depth of 18 feet with a 15 foot screened interval
Driller Justin Radford (GRI)Log By Mike Ellis (GRI)
Lab Sample OVA
Depth Sample Interval(ft)ppm LITHOLOGY
0
0.5' - 4' Orange clay
2
4
6
8
10
12
14
16
18
20
22
24
26
28
30
32
34
36
06/12/19
0 - 0.5' Asphalt
4' - 5' White silt
5' - 18 Direct Push; No Recovery
Well set at 18 feet
WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
Form GW-1 North Carolina Department of Environment and Natural Resources – Division of Water Resources Revised August 2013
1. Well Contractor Information:
Well Contractor Name
NC Well Contractor Certification Number
Company Name 2. Well Construction Permit #:
List all applicable well permits (i.e. County, State, Variance, Injection, etc.)
3. Well Use (check well use): Water Supply Well: □Agricultural □Municipal/Public □Geothermal (Heating/Cooling Supply) □Residential Water Supply (single)
□Industrial/Commercial □Residential Water Supply (shared) □Irrigation
Non-Water Supply Well: □Monitoring □Recovery
Injection Well: □Aquifer Recharge □Groundwater Remediation
□Aquifer Storage and Recovery □Salinity Barrier □Aquifer Test □Stormwater Drainage
□Experimental Technology □Subsidence Control
□Geothermal (Closed Loop) □Tracer □Geothermal (Heating/Cooling Return) □Other (explain under #21 Remarks)
4. Date Well(s) Completed: ____________ Well ID#______________________ 5a. Well Location:
Facility/Owner Name Facility ID# (if applicable)
Physical Address, City, and Zip
County Parcel Identification No. (PIN) 5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees: (if well field, one lat/long is sufficient) N W
6. Is (are) the well(s): □Permanent or □Temporary
7. Is this a repair to an existing well: □Yes or □No
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.
8. Number of wells constructed:
For multiple injection or non-water supply wells ONLY with the same construction, you can
submit one form.
9. Total well depth below land surface: (ft.)
For multiple wells list all depths if different (example- 3@200’ and 2@100′)
10. Static water level below top of casing: (ft.)
If water level is above casing, use “+”
11. Borehole diameter: (in.) 12. Well construction method: (i.e. auger, rotary, cable, direct push, etc.) FOR WATER SUPPLY WELLS ONLY: 13a. Yield (gpm) Method of test: 13b. Disinfection type: Amount:
14. WATER ZONES FROM TO DESCRIPTION
ft. ft.
ft. ft.
15. OUTER CASING (for multi-cased wells) OR LINER (if applicable) FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
16. INNER CASING OR TUBING (geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
ft. ft. in.
17. SCREEN FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
ft. ft. in.
18. GROUT
FROM TO MATERIAL EMPLACEMENT METHOD & AMOUNT
ft. ft.
ft. ft.
ft. ft.
19. SAND/GRAVEL PACK (if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
ft. ft.
20. DRILLING LOG (attach additional sheets if necessary) FROM TO DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
ft. ft.
ft. ft.
ft. ft.
ft. ft.
ft. ft.
ft. ft.
ft. ft.
21. REMARKS
22. Certification:
Signature of Certified Well Contractor Date
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
copy of this record has been provided to the well owner.
23. Site diagram or additional well details: You may use the back of this page to provide additional well site details or well construction details. You may also attach additional pages if necessary. SUBMITTAL INSTUCTIONS 24a. For All Wells: Submit this form within 30 days of completion of well construction to the following: Division of Water Resources, Information Processing Unit, 1617 Mail Service Center, Raleigh, NC 27699-1617 24b. For Injection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well construction to the following: Division of Water Resources, Underground Injection Control Program, 1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion ofwell construction to the county health department of the county whereconstructed.
For Internal Use ONLY:
Justin Radford
3270 A
Geological Resources, Inc.
N/A
06/12/19 MW-8
New Dixie #226 0-0000034646
4917 Raleigh Road Parkway West, Wilson, 27839
Wilson 2793-73-2703
35.695670 77.825220
1
18
5.22
4"
4" Direct push
0 3 2 sch 40 PVC
3 18 2 0.010 sch 40 PVC
0 1 grout pour
1 2 bentonite pour
2 18 #2 sand pour
0 0.5 Asphalt
0.5 4 Orange clay
4 5 White silt
5 18 Direct push; no lithography
6/14/19
Geological Resources, Inc.Phone:(704) 845-4010
3502 Hayes Road Fax:(704) 845-4012
Monroe, NC 28110
SUBSURFACE LOG
Project New Dixie Mart 226
Address 4917 Raleigh Road Parkway W, Wilson, NC
Boring Number MW-9 Date Drilled
Sample Method Grab Drilling Method Direct Push, 4" OD
Completion DetailsWell installed at completion to a total depth of 18 feet with a 15 foot screened interval
Driller Justin Radford (GRI)Log By Mike Ellis (GRI)
Lab Sample OVA
Depth Sample Interval(ft)ppm LITHOLOGY
0
0.5' - 4' Orange clay
2
4
6
8
10
12
14
16
18
20
22
24
26
28
30
32
34
36
06/12/19
0 - 0.5' Asphalt
4 - 5' White Silt
5' - 18' Direct push; no recovery
Well set at 18 feet
WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
Form GW-1 North Carolina Department of Environment and Natural Resources – Division of Water Resources Revised August 2013
1. Well Contractor Information:
Well Contractor Name
NC Well Contractor Certification Number
Company Name 2. Well Construction Permit #:
List all applicable well permits (i.e. County, State, Variance, Injection, etc.)
3. Well Use (check well use): Water Supply Well: □Agricultural □Municipal/Public □Geothermal (Heating/Cooling Supply) □Residential Water Supply (single)
□Industrial/Commercial □Residential Water Supply (shared) □Irrigation
Non-Water Supply Well: □Monitoring □Recovery
Injection Well: □Aquifer Recharge □Groundwater Remediation
□Aquifer Storage and Recovery □Salinity Barrier □Aquifer Test □Stormwater Drainage
□Experimental Technology □Subsidence Control
□Geothermal (Closed Loop) □Tracer □Geothermal (Heating/Cooling Return) □Other (explain under #21 Remarks)
4. Date Well(s) Completed: ____________ Well ID#______________________ 5a. Well Location:
Facility/Owner Name Facility ID# (if applicable)
Physical Address, City, and Zip
County Parcel Identification No. (PIN) 5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees: (if well field, one lat/long is sufficient) N W
6. Is (are) the well(s): □Permanent or □Temporary
7. Is this a repair to an existing well: □Yes or □No
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.
8. Number of wells constructed:
For multiple injection or non-water supply wells ONLY with the same construction, you can
submit one form.
9. Total well depth below land surface: (ft.)
For multiple wells list all depths if different (example- 3@200’ and 2@100′)
10. Static water level below top of casing: (ft.)
If water level is above casing, use “+”
11. Borehole diameter: (in.) 12. Well construction method: (i.e. auger, rotary, cable, direct push, etc.) FOR WATER SUPPLY WELLS ONLY: 13a. Yield (gpm) Method of test: 13b. Disinfection type: Amount:
14. WATER ZONES FROM TO DESCRIPTION
ft. ft.
ft. ft.
15. OUTER CASING (for multi-cased wells) OR LINER (if applicable) FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
16. INNER CASING OR TUBING (geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
ft. ft. in.
17. SCREEN FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
ft. ft. in.
18. GROUT
FROM TO MATERIAL EMPLACEMENT METHOD & AMOUNT
ft. ft.
ft. ft.
ft. ft.
19. SAND/GRAVEL PACK (if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
ft. ft.
20. DRILLING LOG (attach additional sheets if necessary) FROM TO DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
ft. ft.
ft. ft.
ft. ft.
ft. ft.
ft. ft.
ft. ft.
ft. ft.
21. REMARKS
22. Certification:
Signature of Certified Well Contractor Date
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
copy of this record has been provided to the well owner.
23. Site diagram or additional well details: You may use the back of this page to provide additional well site details or well construction details. You may also attach additional pages if necessary. SUBMITTAL INSTUCTIONS 24a. For All Wells: Submit this form within 30 days of completion of well construction to the following: Division of Water Resources, Information Processing Unit, 1617 Mail Service Center, Raleigh, NC 27699-1617 24b. For Injection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well construction to the following: Division of Water Resources, Underground Injection Control Program, 1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion ofwell construction to the county health department of the county whereconstructed.
For Internal Use ONLY:
Justin Radford
3270 A
Geological Resources, Inc.
N/A
06/12/19 MW-9
New Dixie #226 0-0000034646
4917 Raleigh Road Parkway West, Wilson, 27839
Wilson 2793-73-2703
35.695670 77.825220
1
18
6.22
4"
4" Direct push
0 3 2 sch 40 PVC
3 18 2 0.010 sch 40 PVC
0 1 grout pour
1 2 bentonite pour
2 18 #2 sand pour
0 0.5 Asphalt
0.5 4 Orange clay
4 5 White silt
5 18 Direct push; no lithography
6/14/19
Geological Resources, Inc.Phone:(704) 845-4010
3502 Hayes Road Fax:(704) 845-4012
Monroe, NC 28110
SUBSURFACE LOG
Project New Dixie Mart 226
Address 4917 Raleigh Road Parkway W, Wilson, NC
Boring Number MW-10 Date Drilled
Sample Method Grab Drilling Method Auger, 6" OD
Completion DetailsWell installed at completion to a total depth of 18 feet with a 15 foot screened interval
Driller Justin Radford (GRI)Log By Mike Ellis (GRI)
Lab Sample OVA
Depth Sample Interval(ft)ppm LITHOLOGY
0
2
4
6
8
10
12
14
16
18
20
22
24
26
28
30
32
34
36
Well set at 18 feet
06/12/19
0' - 0.5' Asphalt
0.5' - 4' Orange clay
4' - 18' White Silt
WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
Form GW-1 North Carolina Department of Environment and Natural Resources – Division of Water Resources Revised August 2013
1. Well Contractor Information:
Well Contractor Name
NC Well Contractor Certification Number
Company Name 2. Well Construction Permit #:
List all applicable well permits (i.e. County, State, Variance, Injection, etc.)
3. Well Use (check well use): Water Supply Well: □Agricultural □Municipal/Public □Geothermal (Heating/Cooling Supply) □Residential Water Supply (single)
□Industrial/Commercial □Residential Water Supply (shared) □Irrigation
Non-Water Supply Well: □Monitoring □Recovery
Injection Well: □Aquifer Recharge □Groundwater Remediation
□Aquifer Storage and Recovery □Salinity Barrier □Aquifer Test □Stormwater Drainage
□Experimental Technology □Subsidence Control
□Geothermal (Closed Loop) □Tracer □Geothermal (Heating/Cooling Return) □Other (explain under #21 Remarks)
4. Date Well(s) Completed: ____________ Well ID#______________________ 5a. Well Location:
Facility/Owner Name Facility ID# (if applicable)
Physical Address, City, and Zip
County Parcel Identification No. (PIN) 5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees: (if well field, one lat/long is sufficient) N W
6. Is (are) the well(s): □Permanent or □Temporary
7. Is this a repair to an existing well: □Yes or □No
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.
8. Number of wells constructed:
For multiple injection or non-water supply wells ONLY with the same construction, you can
submit one form.
9. Total well depth below land surface: (ft.)
For multiple wells list all depths if different (example- 3@200’ and 2@100′)
10. Static water level below top of casing: (ft.)
If water level is above casing, use “+”
11. Borehole diameter: (in.) 12. Well construction method: (i.e. auger, rotary, cable, direct push, etc.) FOR WATER SUPPLY WELLS ONLY: 13a. Yield (gpm) Method of test: 13b. Disinfection type: Amount:
14. WATER ZONES FROM TO DESCRIPTION
ft. ft.
ft. ft.
15. OUTER CASING (for multi-cased wells) OR LINER (if applicable) FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
16. INNER CASING OR TUBING (geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
ft. ft. in.
17. SCREEN FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
ft. ft. in.
18. GROUT
FROM TO MATERIAL EMPLACEMENT METHOD & AMOUNT
ft. ft.
ft. ft.
ft. ft.
19. SAND/GRAVEL PACK (if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
ft. ft.
20. DRILLING LOG (attach additional sheets if necessary) FROM TO DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
ft. ft.
ft. ft.
ft. ft.
ft. ft.
ft. ft.
ft. ft.
ft. ft.
21. REMARKS
22. Certification:
Signature of Certified Well Contractor Date
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
copy of this record has been provided to the well owner.
23. Site diagram or additional well details: You may use the back of this page to provide additional well site details or well construction details. You may also attach additional pages if necessary. SUBMITTAL INSTUCTIONS 24a. For All Wells: Submit this form within 30 days of completion of well construction to the following: Division of Water Resources, Information Processing Unit, 1617 Mail Service Center, Raleigh, NC 27699-1617 24b. For Injection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well construction to the following: Division of Water Resources, Underground Injection Control Program, 1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion ofwell construction to the county health department of the county whereconstructed.
For Internal Use ONLY:
Justin Radford
3270 A
Geological Resources, Inc.
N/A
06/12/19 MW-10
New Dixie #226 0-0000034646
4917 Raleigh Road Parkway West, Wilson, 27839
Wilson 2793-73-2703
35.695670 77.825220
1
18
10.65
6"
6" OD HSA auger
0 3 2 sch 40 PVC
3 18 2 0.010 sch 40 PVC
0 1 grout pour
1 2 bentonite pour
2 18 #2 sand pour
0 0.5 Asphalt
0.5 4 Orange clay
4 18 White silt
6/14/19
Geological Resources, Inc.Phone:(704) 845-4010
3502 Hayes Road Fax:(704) 845-4012
Monroe, NC 28110
SUBSURFACE LOG
Project New Dixie Mart 226
Address 4917 Raleigh Road Parkway W, Wilson, NC
Boring Number MW-11 Date Drilled
Sample Method Grab Drilling Method Auger, 6" OD
Completion DetailsWell installed at completion to a total depth of 18 feet with a 15 foot screened interval
Driller Justin Radford (GRI)Log By Mike Ellis (GRI)
Lab Sample OVA
Depth Sample Interval(ft)ppm LITHOLOGY
0
2
4
6
8
10
12
14
16
18
20
22
24
26
28
30
32
34
36
Well set at 18 feet
06/12/19
0' - 0.5' Asphalt
0.5' - 4' Orange clay
4' - 18' White Silt
WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
Form GW-1 North Carolina Department of Environment and Natural Resources – Division of Water Resources Revised August 2013
1. Well Contractor Information:
Well Contractor Name
NC Well Contractor Certification Number
Company Name 2. Well Construction Permit #:
List all applicable well permits (i.e. County, State, Variance, Injection, etc.)
3. Well Use (check well use): Water Supply Well: □Agricultural □Municipal/Public □Geothermal (Heating/Cooling Supply) □Residential Water Supply (single)
□Industrial/Commercial □Residential Water Supply (shared) □Irrigation
Non-Water Supply Well: □Monitoring □Recovery
Injection Well: □Aquifer Recharge □Groundwater Remediation
□Aquifer Storage and Recovery □Salinity Barrier □Aquifer Test □Stormwater Drainage
□Experimental Technology □Subsidence Control
□Geothermal (Closed Loop) □Tracer □Geothermal (Heating/Cooling Return) □Other (explain under #21 Remarks)
4. Date Well(s) Completed: ____________ Well ID#______________________ 5a. Well Location:
Facility/Owner Name Facility ID# (if applicable)
Physical Address, City, and Zip
County Parcel Identification No. (PIN) 5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees: (if well field, one lat/long is sufficient) N W
6. Is (are) the well(s): □Permanent or □Temporary
7. Is this a repair to an existing well: □Yes or □No
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.
8. Number of wells constructed:
For multiple injection or non-water supply wells ONLY with the same construction, you can
submit one form.
9. Total well depth below land surface: (ft.)
For multiple wells list all depths if different (example- 3@200’ and 2@100′)
10. Static water level below top of casing: (ft.)
If water level is above casing, use “+”
11. Borehole diameter: (in.) 12. Well construction method: (i.e. auger, rotary, cable, direct push, etc.) FOR WATER SUPPLY WELLS ONLY: 13a. Yield (gpm) Method of test: 13b. Disinfection type: Amount:
14. WATER ZONES FROM TO DESCRIPTION
ft. ft.
ft. ft.
15. OUTER CASING (for multi-cased wells) OR LINER (if applicable) FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
16. INNER CASING OR TUBING (geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
ft. ft. in.
17. SCREEN FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
ft. ft. in.
18. GROUT
FROM TO MATERIAL EMPLACEMENT METHOD & AMOUNT
ft. ft.
ft. ft.
ft. ft.
19. SAND/GRAVEL PACK (if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
ft. ft.
20. DRILLING LOG (attach additional sheets if necessary) FROM TO DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
ft. ft.
ft. ft.
ft. ft.
ft. ft.
ft. ft.
ft. ft.
ft. ft.
21. REMARKS
22. Certification:
Signature of Certified Well Contractor Date
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
copy of this record has been provided to the well owner.
23. Site diagram or additional well details: You may use the back of this page to provide additional well site details or well construction details. You may also attach additional pages if necessary. SUBMITTAL INSTUCTIONS 24a. For All Wells: Submit this form within 30 days of completion of well construction to the following: Division of Water Resources, Information Processing Unit, 1617 Mail Service Center, Raleigh, NC 27699-1617 24b. For Injection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well construction to the following: Division of Water Resources, Underground Injection Control Program, 1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion ofwell construction to the county health department of the county whereconstructed.
For Internal Use ONLY:
Justin Radford
3270 A
Geological Resources, Inc.
N/A
06/12/19 MW-11
New Dixie #226 0-0000034646
4917 Raleigh Road Parkway West, Wilson, 27839
Wilson 2793-73-2703
35.695670 77.825220
1
18
11.71
6"
6" OD HSA auger
0 3 2 sch 40 PVC
3 18 2 0.010 sch 40 PVC
0 1 grout pour
1 2 bentonite pour
2 18 #2 sand pour
0 0.5 Asphalt
0.5 4 Orange clay
4 18 White silt
6/14/19
Geological Resources, Inc.Phone:(704) 845-4010
3502 Hayes Road Fax:(704) 845-4012
Monroe, NC 28110
SUBSURFACE LOG
Project New Dixie Mart 226
Address 4917 Raleigh Road Parkway W, Wilson, NC
Boring Number MW-12 Date Drilled
Sample Method Grab Drilling Method Direct Push, 4" OD
Completion DetailsWell installed at completion to a total depth of 18 feet with a 15 foot screened interval
Driller Justin Radford (GRI)Log By Mike Ellis (GRI)
Lab Sample OVA
Depth Sample Interval(ft)ppm LITHOLOGY
0
1' - 5' Orange clay
2
4
6
8
10
12
14
16
18
20
22
24
26
28
30
32
34
36
06/12/19
0' - 1' Brown fine sand
5' - 18' Direct push; no recovery
Well set at 18 feet
WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
Form GW-1 North Carolina Department of Environment and Natural Resources – Division of Water Resources Revised August 2013
1. Well Contractor Information:
Well Contractor Name
NC Well Contractor Certification Number
Company Name 2. Well Construction Permit #:
List all applicable well permits (i.e. County, State, Variance, Injection, etc.)
3. Well Use (check well use): Water Supply Well: □Agricultural □Municipal/Public □Geothermal (Heating/Cooling Supply) □Residential Water Supply (single)
□Industrial/Commercial □Residential Water Supply (shared) □Irrigation
Non-Water Supply Well: □Monitoring □Recovery
Injection Well: □Aquifer Recharge □Groundwater Remediation
□Aquifer Storage and Recovery □Salinity Barrier □Aquifer Test □Stormwater Drainage
□Experimental Technology □Subsidence Control
□Geothermal (Closed Loop) □Tracer □Geothermal (Heating/Cooling Return) □Other (explain under #21 Remarks)
4. Date Well(s) Completed: ____________ Well ID#______________________ 5a. Well Location:
Facility/Owner Name Facility ID# (if applicable)
Physical Address, City, and Zip
County Parcel Identification No. (PIN) 5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees: (if well field, one lat/long is sufficient) N W
6. Is (are) the well(s): □Permanent or □Temporary
7. Is this a repair to an existing well: □Yes or □No
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.
8. Number of wells constructed:
For multiple injection or non-water supply wells ONLY with the same construction, you can
submit one form.
9. Total well depth below land surface: (ft.)
For multiple wells list all depths if different (example- 3@200’ and 2@100′)
10. Static water level below top of casing: (ft.)
If water level is above casing, use “+”
11. Borehole diameter: (in.) 12. Well construction method: (i.e. auger, rotary, cable, direct push, etc.) FOR WATER SUPPLY WELLS ONLY: 13a. Yield (gpm) Method of test: 13b. Disinfection type: Amount:
14. WATER ZONES FROM TO DESCRIPTION
ft. ft.
ft. ft.
15. OUTER CASING (for multi-cased wells) OR LINER (if applicable) FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
16. INNER CASING OR TUBING (geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
ft. ft. in.
17. SCREEN FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
ft. ft. in.
18. GROUT
FROM TO MATERIAL EMPLACEMENT METHOD & AMOUNT
ft. ft.
ft. ft.
ft. ft.
19. SAND/GRAVEL PACK (if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
ft. ft.
20. DRILLING LOG (attach additional sheets if necessary) FROM TO DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
ft. ft.
ft. ft.
ft. ft.
ft. ft.
ft. ft.
ft. ft.
ft. ft.
21. REMARKS
22. Certification:
Signature of Certified Well Contractor Date
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
copy of this record has been provided to the well owner.
23. Site diagram or additional well details: You may use the back of this page to provide additional well site details or well construction details. You may also attach additional pages if necessary. SUBMITTAL INSTUCTIONS 24a. For All Wells: Submit this form within 30 days of completion of well construction to the following: Division of Water Resources, Information Processing Unit, 1617 Mail Service Center, Raleigh, NC 27699-1617 24b. For Injection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well construction to the following: Division of Water Resources, Underground Injection Control Program, 1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion ofwell construction to the county health department of the county whereconstructed.
For Internal Use ONLY:
Justin Radford
3270 A
Geological Resources, Inc.
N/A
06/12/19 MW-12
New Dixie #226 0-0000034646
4917 Raleigh Road Parkway West, Wilson, 27839
Wilson 2793-73-2703
35.695670 77.825220
1
18
11.01
4"
4" Direct push
0 3 2 sch 40 PVC
3 18 2 0.010 sch 40 PVC
0 1 grout pour
1 2 bentonite pour
2 18 #2 sand pour
0 1 Brown fine sand
1 5 Orange clay
5 18 Direct push; no lithography
6/14/19
Geological Resources, Inc.Phone:(704) 845-4010
3502 Hayes Road Fax:(704) 845-4012
Monroe, NC 28110
SUBSURFACE LOG
Project New Dixie Mart 226
Address 4917 Raleigh Road Parkway W, Wilson, NC
Boring Number MW-13 Date Drilled
Sample Method Grab Drilling Method 6" Solid Stem Augers
Completion DetailsWell installed at completion to a total depth of 20 feet with a 15 foot screened interval
Driller Samuel Bowers (GRI)Log By Samuel Bowers (GRI)
Lab Sample OVA
Depth Sample Interval(ft)ppm LITHOLOGY
0
0.25' - 1' Gravel (subbase)
2
4
6
8
10
12
14
16
18
20
22
24
26
28
30
32
34
36
02/05/20
0' - 0.25' Asphalt
1' - 3' Tan fine sand
3' - 5' Brown sandy clay
5' - 6' Tan/White sandy clay
6' - 10' Tan clay
10' - 12' Tan sandy clay
12' - 13' Tan/White silty fine sand
13' - 15' Tan silt with rock stringers
15' - 17' Tan silt
17' - 20' Brown silt
Well set at 20 feet
WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
Form GW-1 North Carolina Department of Environment and Natural Resources – Division of Water Resources Revised August 2013
1. Well Contractor Information:
Well Contractor Name
NC Well Contractor Certification Number
Company Name 2. Well Construction Permit #:
List all applicable well permits (i.e. County, State, Variance, Injection, etc.)
3. Well Use (check well use): Water Supply Well: □Agricultural □Municipal/Public □Geothermal (Heating/Cooling Supply) □Residential Water Supply (single)
□Industrial/Commercial □Residential Water Supply (shared) □Irrigation
Non-Water Supply Well: □Monitoring □Recovery
Injection Well: □Aquifer Recharge □Groundwater Remediation
□Aquifer Storage and Recovery □Salinity Barrier □Aquifer Test □Stormwater Drainage
□Experimental Technology □Subsidence Control
□Geothermal (Closed Loop) □Tracer □Geothermal (Heating/Cooling Return) □Other (explain under #21 Remarks)
4. Date Well(s) Completed: ____________ Well ID#______________________ 5a. Well Location:
Facility/Owner Name Facility ID# (if applicable)
Physical Address, City, and Zip
County Parcel Identification No. (PIN) 5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees: (if well field, one lat/long is sufficient) N W
6. Is (are) the well(s): □Permanent or □Temporary
7. Is this a repair to an existing well: □Yes or □No
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.
8. Number of wells constructed:
For multiple injection or non-water supply wells ONLY with the same construction, you can
submit one form.
9. Total well depth below land surface: (ft.)
For multiple wells list all depths if different (example- 3@200’ and 2@100′)
10. Static water level below top of casing: (ft.)
If water level is above casing, use “+”
11. Borehole diameter: (in.) 12. Well construction method: (i.e. auger, rotary, cable, direct push, etc.) FOR WATER SUPPLY WELLS ONLY: 13a. Yield (gpm) Method of test: 13b. Disinfection type: Amount:
14. WATER ZONES FROM TO DESCRIPTION
ft. ft.
ft. ft.
15. OUTER CASING (for multi-cased wells) OR LINER (if applicable) FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
16. INNER CASING OR TUBING (geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
ft. ft. in.
17. SCREEN FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
ft. ft. in.
18. GROUT
FROM TO MATERIAL EMPLACEMENT METHOD & AMOUNT
ft. ft.
ft. ft.
ft. ft.
19. SAND/GRAVEL PACK (if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
ft. ft.
20. DRILLING LOG (attach additional sheets if necessary) FROM TO DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
ft. ft.
ft. ft.
ft. ft.
ft. ft.
ft. ft.
ft. ft.
ft. ft.
21. REMARKS
22. Certification:
Signature of Certified Well Contractor Date
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
copy of this record has been provided to the well owner.
23. Site diagram or additional well details: You may use the back of this page to provide additional well site details or well construction details. You may also attach additional pages if necessary. SUBMITTAL INSTUCTIONS 24a. For All Wells: Submit this form within 30 days of completion of well construction to the following: Division of Water Resources, Information Processing Unit, 1617 Mail Service Center, Raleigh, NC 27699-1617 24b. For Injection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well construction to the following: Division of Water Resources, Underground Injection Control Program, 1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion ofwell construction to the county health department of the county whereconstructed.
For Internal Use ONLY:
Samuel Bowers
3220
Geological Resources, Inc.
WM0501386
02/05/20 MW-13
New Dixie #226 0-0000034646
4917 Raleigh Road Parkway West, Wilson, 27839
Wilson 2793-73-2703
35.695670 77.825220
1
20
6.50
6"
6" OD SS Augers
0 5 2 sch 40 PVC
5 20 2 0.010 sch 40 PVC
0 1 grout pour
1 3 bentonite pour
3 20 #2 sand pour
0 1 gravel
1 3 Tan fine sand
3 5 Brown sandy clay
5 12 Tan/White sandy clay
12 17 Tan/white silt
17 20 Brown silt
2/14/20
Geological Resources, Inc.Phone:(704) 845-4010
3502 Hayes Road Fax:(704) 845-4012
Monroe, NC 28110
SUBSURFACE LOG
Project New Dixie Mart 226
Address 4917 Raleigh Road Parkway W, Wilson, NC
Boring Number TW-1 Date Drilled
Sample Method Grab Drilling Method
Completion DetailsWell installed total depth 50 feet, 5 foot screen, outer casing set at 30 feet
Driller Ransier EnviroDrill Log By Ethan Rogerson (GRI)
Lab Sample OVA
Depth Sample Interval(ft)ppm LITHOLOGY
0
3
6
9
12
15
18
21
24
27
30
33
36
39
42
45
48
51
54
Well set at 50'
24' - 30' Tan silt
30' set outter casing
30' - 50' tan fine sandy silt
8' - 24' light tan silt
5' - 8' Gray sand
06/18/19
0' - 0.5' Gravel
0.5' - 5' Brown sand
8" HSA/ 5" Air Hammer
WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
Form GW-1 North Carolina Department of Environment and Natural Resources – Division of Water 5HVRXUFHV Revised AXJXVW 2013
1. Well Contractor Information:
Well Contractor Name
NC Well Contractor Certification Number
Company Name 2. Well Construction Permit #: List all applicable well permits (i.e. County, State, Variance, ,QMHFWLRQetc.) 3. Well Use (check well use): Water Supply Well: □Agricultural □Municipal/Public □Geothermal (Heating/Cooling Supply) □Residential Water Supply (single)
□Industrial/Commercial □Residential Water Supply (shared) □Irrigation
Non-Water Supply Well: □Monitoring □Recovery
Injection Well: □Aquifer Recharge □Groundwater Remediation
□Aquifer Storage and Recovery □Salinity Barrier □Aquifer Test □Stormwater Drainage
□Experimental Technology □Subsidence Control
□Geothermal (Closed Loop) □Tracer □Geothermal (Heating/Cooling Return) □Other (explain under #21 Remarks)
4. Date Well(s) Completed: ____________ Well ID#______________________ 5a. Well Location:
Facility/Owner Name Facility ID# (if applicable)
Physical Address, City, and Zip
County Parcel Identification No. (PIN) 5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees: (if well field, one lat/long is sufficient) N W
6. Is (are) the well(s): □Permanent or □Temporary
7. Is this a repair to an existing well: □Yes or □No 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.
8. Number of wells constructed: For multiple injection or non-water supply wells ONLY with the same construction, you can submit one form. 9. Total well depth below land surface: (ft.) For multiple wells list all depths if different (example- 3@200’ and 2@100′) 10. Static water level below top of casing: (ft.) If water level is above casing, use “+” 11. Borehole diameter: (in.) 12. Well construction method: (i.e. auger, rotary, cable, direct push, etc.) FOR WATER SUPPLY WELLS ONLY: 13a. Yield (gpm) Method of test: 13b. Disinfection type: Amount:
14. WATER ZONES
FROM TO DESCRIPTION
ft. ft.
ft. ft.
15. OUTER CASING (for multi-cased wells) OR LINER (if applicable) FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
16. INNER CASING OR TUBING (geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
ft. ft. in.
17. SCREEN FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
ft. ft. in.
18. GROUT
FROM TO MATERIAL EMPLACEMENT METHOD & AMOUNT
ft. ft.
ft. ft.
ft. ft.
19. SAND/GRAVEL PACK (if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
ft. ft.
20. DRILLING LOG (attach additional sheets if necessary) FROM TO DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
ft. ft.
ft. ft.
ft. ft.
ft. ft.
ft. ft.
ft. ft.
ft. ft.
21. REMARKS
22. Certification:
Signature of Certified Well Contractor Date 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 copy of this record has been provided to the well owner.
23. Site diagram or additional well details: You may use the back of this page to provide additional well site details or well construction details. You may also attach additional pages if necessary. SUBMITTAL INSTUCTIONS 24a. For All Wells: Submit this form within 30 days of completion of well construction to the following: Division of Water Resources, Information Processing Unit, 1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well construction to the following: Division of Water Resources, Underground Injection Control Program, 1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion ofwell construction to the county health department of the county whereconstructed.
For Internal Use ONLY:
Geological Resources, Inc.Phone:(704) 845-4010
3502 Hayes Road Fax:(704) 845-4012
Monroe, NC 28110
SUBSURFACE LOG
Project New Dixie Mart 226
Address 4917 Raleigh Road Parkway West, Wilson, NC
Boring Number TW-2 Date Drilled
Sample Method N/A Drilling Method
Completion DetailsWell installed total depth 75 feet, 5 foot screen, outer casing to 60 feet
Driller Bryan Vest (NC Cert. # 3580)Log By William R. & Matthew S.
Lab Sample OVA
Depth Sample Interval(ft)ppm LITHOLOGY
0
5
10
15
20
25
28' - 36' Gray Clay and Rock
30
35
40
45
50
55
60
65 Outer casing set at 65'
65' - 75' Gray Rock
70
75
80
85
90
Well set at 75'
36' - 65' Gray Rock, tan limestone
2/13/20-2/14/20
9" air hammer/ 5" air hammer
0' - 0.25' Asphalt
0.25' - 12' Red Brown becoming Light Brown Silt
12' - 18' White Clayey Silt
18' - 28' White to Light Brown Silty Coarse Sand
WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
Form GW-1 North Carolina Department of Environment and Natural Resources – Division of Water 5HVRXUFHV Revised AXJXVW 2013
1. Well Contractor Information:
Well Contractor Name
NC Well Contractor Certification Number
Company Name 2. Well Construction Permit #: List all applicable well permits (i.e. County, State, Variance, ,QMHFWLRQetc.) 3. Well Use (check well use): Water Supply Well: □Agricultural □Municipal/Public □Geothermal (Heating/Cooling Supply) □Residential Water Supply (single)
□Industrial/Commercial □Residential Water Supply (shared) □Irrigation
Non-Water Supply Well: □Monitoring □Recovery
Injection Well: □Aquifer Recharge □Groundwater Remediation
□Aquifer Storage and Recovery □Salinity Barrier □Aquifer Test □Stormwater Drainage
□Experimental Technology □Subsidence Control
□Geothermal (Closed Loop) □Tracer □Geothermal (Heating/Cooling Return) □Other (explain under #21 Remarks)
4. Date Well(s) Completed: ____________ Well ID#______________________ 5a. Well Location:
Facility/Owner Name Facility ID# (if applicable)
Physical Address, City, and Zip
County Parcel Identification No. (PIN) 5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees: (if well field, one lat/long is sufficient) N W
6. Is (are) the well(s): □Permanent or □Temporary
7. Is this a repair to an existing well: □Yes or □No 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.
8. Number of wells constructed: For multiple injection or non-water supply wells ONLY with the same construction, you can submit one form. 9. Total well depth below land surface: (ft.) For multiple wells list all depths if different (example- 3@200’ and 2@100′) 10. Static water level below top of casing: (ft.) If water level is above casing, use “+” 11. Borehole diameter: (in.) 12. Well construction method: (i.e. auger, rotary, cable, direct push, etc.) FOR WATER SUPPLY WELLS ONLY: 13a. Yield (gpm) Method of test: 13b. Disinfection type: Amount:
14. WATER ZONES
FROM TO DESCRIPTION
ft. ft.
ft. ft.
15. OUTER CASING (for multi-cased wells) OR LINER (if applicable) FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
16. INNER CASING OR TUBING (geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
ft. ft. in.
17. SCREEN FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
ft. ft. in.
18. GROUT
FROM TO MATERIAL EMPLACEMENT METHOD & AMOUNT
ft. ft.
ft. ft.
ft. ft.
19. SAND/GRAVEL PACK (if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
ft. ft.
20. DRILLING LOG (attach additional sheets if necessary) FROM TO DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
ft. ft.
ft. ft.
ft. ft.
ft. ft.
ft. ft.
ft. ft.
ft. ft.
21. REMARKS
22. Certification:
Signature of Certified Well Contractor Date 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 copy of this record has been provided to the well owner.
23. Site diagram or additional well details: You may use the back of this page to provide additional well site details or well construction details. You may also attach additional pages if necessary. SUBMITTAL INSTUCTIONS 24a. For All Wells: Submit this form within 30 days of completion of well construction to the following: Division of Water Resources, Information Processing Unit, 1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well construction to the following: Division of Water Resources, Underground Injection Control Program, 1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion ofwell construction to the county health department of the county whereconstructed.
For Internal Use ONLY: