GW1-2021-00268_Well Construction - GW1_20210126

WELL CONSTRUCTION RECORD Fnt Internal u,eONL't
Tha form can be used to single or nniluple.,dls
1.Well Contractor Information:
Justin Radford I/.WATER ZONES
Enoal TO DFscRnrnoK
'Aell C.mVacwr Name 15 ft 20 °• Brown-tan coarse clayey sand
3270 A ft. f.
NC Rall Contractor C'enificmum Nmnber MOUTERCAS Ifor mtd M tl- ells OR LINER ifa liabl e
FROM 1'0 DEA\Il:Tf:R 1'f11CKN ESS MATE.RIAI.
Geological Resources, Inc. rl. ft. in.
Contpanc Name 16.INNER CASING OR TUBING eolbermal closed-loo
FROM to UTA\it R 1"flit K%ESS MATERUI.
2.\Iell Construction Permit#: p ❑, 10 h' 2" in' sch 40 PVC
l nr,dl..ppLmhlr.rcll per nun ne tounit.tint:_17uvon,.: lrp.,mm..I,.I
D. ft. in.
3.\\ell Use(check well use): I7.SCREEN
Hater Supply Well: FROM 10 DIAMETER SLOT SIZE: Too KNESS NIATE.RIAL
C:\2ricultural ❑MunicipabPublic 10 f'' 20 f'' 2 '"' 0.010 Sch 40 PVC
Geothemlal(Ilealing'Coolin_e Supph) ❑Residential H aler Supph (sin^_le) ft. ft. in.
Indu,trial,Cummercial ❑Residential l\aler Supph (shared) I&GROAT
FROM to MATERIAL EMPLaCE.MENTMETHOD&.AMOI]T
❑hngauon 0 D' 6 D- Concrete Pour
Non-N aler Supply Well: 6 f'' 6 °• eentonite Pour
2 Moniturin2 ❑Rcco%erc
Injection Nell: ft. ft.
;Aquifer Recharge ❑GroundeNater Renlediation 19.SAND/GRAVEL PACK ifa livable
FROM 10 MATF:RI:V. EMPI.Ar'EMENTME:1'1101)
❑Aquifer Storage and Reco%ery ❑Salinity Barrier ft h
8 20 Sand Pour
❑Ayuiler Tcst ❑Slormwaler Drainage
1t. ft.
❑Fxperimental Technologc ❑Subsidence Control
20.DRILLING LOG am additional sheets if necessa
-Gcotherulal(Closed l(unp) El racer FROM To DESCRIPTION some,h,.an—..otu.o<sn - —or.,
-(leothennal(I leatim,Cooling Return) ❑Other te%plain under 421 Remarks) 0 fl. .5 ft. Asphalt
01/04/2021 MW-2 0.5 fL 4 ft. Gray sandy clay
J.Date \'ell(s)('+lmpleted: Well Ill#
4 f'• 6 f'• Light brown
5a.\fell Location: 6 ft. 9 ft. Red and gray clay
EP Mart 16 0-0000036065 9 h- 17 ft. Brown clay
Facihn O..ner Name I'a,hn I)=t if applicable)
17 °- 20 °. Brown course to coed sand
1800 Benvenue Road, Rocky Mounty, NC fL
Ph,meal Address,City.and Zip
21.REMARKS
Edgecombe 3851-0915-6185 Sample collected at 10'
Cnuntr Parcel ldenuficanon No WIN)
5b,Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 12.(ertificatian:
of ,ell field.line Iatilong i,sulliciem)
35.984253 N 77.812519 N 911l 01/08/2021
Signature M C'coilied Rk 11 Contractor [)at,
6.Is(are)the Melbs): CPermanent or El emporary it, .Ivmng d", n,.... I hnvht r,vw, ha,the udl.v „ ,on,mnnv..ed,n.t .onlmt..
u It,151.M'.I( II'('JHno or l,d \(_R a'(' 0,00 II'r/1 t bnarwu„n Sian.I 1111,mnhhnt.t
7. Is this a repair to an existing well: ❑tics or ENo W d....rwvdh,..he,,pn.nded h,dm.crll...rnr..
11thnne"r....,1ilt uul A.....n"c/I amvrucunn...It nununt,nnl nrplmn Ihr..nave n)the
rfp.... under 2I..murk,uemm.n,utIt,h...k a/Ihi.lnrm. 23.Site diagram or additional well details:
You nlay use the back of this page to provide additional hell site details or well
S.Number of wells constructed: construction details. You may also attach additional pages it necessan_
h........ le.nleo om........) nr,t .uppitvdhO,VL In ah Ih,sameconstruction. ratan
,nhnul:me l.,r n. n 11 St'B�Il1'f.-AL INS1 C( IFONS
9.'fotal well depth below land surface. 20 (ft.) 24a For .UI N'clls: Submit this tuna within 30 days of completion of well
1",rnu/uple vclL.liar ul/Jrplh.J.Lry.ran(erw.gW,-3 a'00 mid,a 100') construction[,,Tile fol lnwin2'.
10.Static water level below top of casing: 11 .12 (ft.) Division of H ater Resources.Information Processing Cnit.
II nawrl,-col.,ehorr........ .... 1617 Mail Service('enter.Raleigh.NC 27699-1617
n
11.Borehole diameter. 6 (in.) 246. For Iniection \1 ell s ONL1: In addition to sending the form to the address in
Auger
6" Steel Flight Au Jaabove. ulS0 Submit a copy of this form within 30 day of completion of well
12.%Nell construction method: g g construction to the folho%in2.
r a queer.ratan-,cable,direct push.etc.,
Dicisiml of NA ater Resources,Cnderground Injection Control Program.
FOR N ATER St PPLI MELLS ONIA: 1636)tail SerN ice Center,Raleigh.NC 27699-1636
13a.l ield(gpm) .Method of test: _ 24c, For Hater Supph & Injection Nells:
Also submit one cop% of this foml within 30 days of completion of
13b.Disinfection type: Amount'— well construction to the count)' health department of the counh'where
constructed_
Fort,GU'-I North Cun,Iuta Depnnmm of I onortmcnl and Natural R,,ounrs 1)....mn ofN;re,Rcmvnce, Recucd Auenst 301',