GW1-2021-00263_Well Construction - GW1_20210126

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WAFER ZONES
Justin Radford FROM TO DESCRIPTION
Well Contractor Name 1 R• 12 ft• Tan to gray sandy clay
3270 A . ' 1 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for°multi-cased wells ?LLINER:if a `licable
�ftTo
DIAMETERTHICESS MATERIAL
Geological Resources, Inc. ft. I in.
Company Name 16.INNER CASING OR_7 ,BING `e'dMifmal`closed-loop
WM0701239FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 2 ft. 2„ i"• SCh 40 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 2 tt' 10 ft 2 in. 0.010 SCh 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water SuPPIY(single) tt. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) I&GROUT �< <. .•.`
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 0.5 rL Concrete Pour
Non-Water Supply Well:
©Monitoring ❑Recovery 0.5 ft 1.0 tt bentonite Pour
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SANu/GRAVgL,PACK,;f a licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 2 tt. 12 ft Sand Pour
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
<20.DRILLING LOG.attacb_additional'sheetsif nice ssa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 4 Tan sandy clay
4.Date Well(s)Completed: Well ID#
01/05/2021 MW-0 4 tt• 12 ft Direct push; no recovery
ft. ft.
5a.Well Location:
CB Jones Texaco N/A
Facility/Owner Name Facility ID#(if applicable) ft. ft.
NC Route 42 and SR 1321, Powellsville, NC 27967 ft ft
Physical Address,City,and Zip -IL REMARKS
Bertie 6910-07-0329
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one lat/long is sufficient)
36.225643 N 76.932432 W 01/08/2021
Signature of Certified Well Contractor Date
6.Is(are)the well(s): laPermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)consiructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 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 ofthis 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 sane construction,you can
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 10 ([t� .,Z4N For All Wells: Submit this form within 30 days of completion of well
For multiple we/Is list all depths if different(example-3 tt 200'and 2 a " )j <• Astruetion to the following:
10.Static water level below top of casing: 0.00t02� Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" J hN 1617 Mail Service Center,Raleigh,NC 27699-1617
0 31# >H,]n11
11.Borehole diameter: 3•5 (in.) r�rOOQ� or Infection Wells ONLY: In addition to sending the form to the address in
Hand Au er/Dire�tiSptS§ a1yBt���ELt:t�above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: g �wy 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