GW1-2021-00267_Well Construction - GW1_20210126

SRUCTION RECORD For Internal use ONLY:
V*hif!_�M.S?.sedfTsingle or multiple wells
1.Well Contractor Information:
14.WATER ZONES
Justin Radford FROM TO
DESCRIPTION
Well Contractor Name 0.6" tt• 12' ft tan to gray silty clay
3270 A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for iiiuIh-cased wells ORI_LINER if a- licable
FROM TO DIAMETER THICKNESS MATERIAL
Geological Resources, Inc. tt. ft. I in.
116.:INNER CASING-'OR TUBING eothermal closed-foo`'`h .
Company Name
WM0701238FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: p 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 ft' 12 ft 2 in. 0.010 SCh 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) tt. ft• in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18:�GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 ft' 0.5 ft. Concrete Pour
Non-Water Supply Well:
0.5 ft 1.0 ft Bentonite Pour
Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACIC 1f ajil"`lie ble`
FROM TO ,MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 1 ft. 12 ft' Sand Pouf
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
`.20.DRILLING;L`OG(attieh,ailditidhA5I Bets if nec'essa "`
❑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 rt. 4 ft. Tan sandy clay
4.Date Well(s)Completed: Well ID#
01/05/2021 MW-31 4 rL 12 ft. Direct push; no recovery
tt. ft.
5a.Well Location:
Red Apple Market #12 0-0000022799
Facility/Owner Name Facility ID#-(if applicable)
3336 US Hwy 13 N, Powellsville, NC 27967
Physical Address,City,and Zip 21,REMARKS
Bertie 6900-78-8498
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one fat/long is sufficient) 1/
36.22975 N 76.933167 W �Q 01/08/2021
Signature of Certified Well Contractor Date
6.Is(are)the well(s): 2Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ENO copy oflhis 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 oflhis 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.
Far multiple injection or non-wafer supply wells ONLY wish the same construction,you can
submit oneform. SUBMITTAL INSTUCTIONS
(C` tywR 2,�. .
9.Total well depth below land surface: 12 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@100') �Iv b 7l0"struction to the following:
10.Static water level below top of casing: 0.20 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" �4 ��iOy� -r!11;r, S;h ul'II 1617 Mail Service Center,Raleigh,NC 27699-1617
3.5 a yt O214b. For Infection Wells ONLY: In addition to sending the form to the address in
11.Borehole diameter: (in.) g
Hand Au /Direct h 24a above, also submit a copy of this form within 30 days of completion of well
Auger/Direct US
12.Well construction method: g 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