GW1-2021-00628_Well Construction - GW1_20210326

WELL CONSTRUCTION RECORD Fa,hm,unt oar ONI r_
This form can be need tor,iimIc o,multiple wells
1.Well Contractor Information:
Jonathan R. Grubbs 14.WATER TONES
FROM TO DESCRIPTION
Well Contractor Name f`. ft.
3001 ft. ft.
NC Nell Contractor C,nor,, ion Number 15.OUTER CASING for multiwased wells OR LINER cable ifa B
FROST TO UI UIEI'ER THICKNESS MATERIAL
Terraquest Environmental Consultants, P.C. ft. ft.
Company Name 16.INNER CASING OR TUBING eothermalelmed-loo
FROM TO UTAMETER THICKNESS MATERIAL
2.Well Construction Permit#: R. ft. in.
Lot oll apphcahle e•ell pennicv o e_( unrry San,, Yanmme,7tgecaan.erc)
ft. fr in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 30 h. 35 ft 1 in' .010 SCh.40 PVC
❑Geothermal(Healing/Cooling Supply) ❑Residential Water Supply(single) fc I ft. in.
❑Industrial/Com mere ial ❑Residential Water Supply(shared) 18.GROUT
FROM To M.ATERLAI, EMPIACEMENT METHOD&AMOUNT
❑Irrigation 0 f`• 16 1t Portland Pour
Non-Water Supply Well:
ZMonitm ing ❑Recovery. 16 f° 18 Bentonite Pour
Injection Well: 0 ft
❑Aquifer Recharge ❑Groundwater Remedmoon 19.SAND/GRAVEL PACK( applienble
FROM TO MATERLU. ENIPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
18 f'� 25 f` No.2 Sand Pour
❑Aquifer Test ❑Stonnwater Drainage
ft. fL
❑Experimental Technology []Subsidence Control
20.DRILLING LOG stash xiddid P sheets if necessary)
❑Geothermal(Closed Loop) ❑ DESCRIPTION
Traczr FROM To DEscRIPTloN romr.harenra:,,inuracx , u.erc.
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under 421 Remarks) 0 ut- 0.25 1t- Asphalt
4.Date Well(s)Completed: Well IDf✓�
3/9/2021 SP1, ASP3, ASP5 025 " 20 t. Sandy Lean Clay(CL)
20 ft- 25 °. Clayey Sand(SC)
-is.Well Location: ft. ft.
Poco #1 Parnell Oil Comp. 0-021993 ft t
Faeditylowner Name Fiinlov ID=(ifappllcable)
97 N. Fayetteville St. Parkton NC 28371 ft IT,
Physical Address,City,and Zip 21 REMARKS
Robeson 949169844900
Comb Patcel Identification No (PIN) -'-- -
51E.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
of,dl field,one let/lang is sufficient)
34.9026 N 78.0105 11. -� ecPls -• = 3i24i2021
Sibieum,ofC,mfied Well Cantmaitr Nat,
6.Is(are)the well(s): OPermanent or ❑Temporary B, ngnmg on,jmn, 1 hereb, cent6 Mw the aehpl war(t.ere,an oo,red in oo,,oa nog
eath 13A N('A( 02C'.0100 or lad,y('AC 02('.0200[Yell('nv.vmmnan.lrandards and that a
7.Is this a repair to an existing well: ❑Yes or KlNo cope oj&is record has been prmadeAro rhu well owner.
lJ thu is a repair,Jill our known well conomnion informafiun and explain the natnre of the
repo,,an1er=21 rernarke seerion or on the hook offhts form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.
Number ofwells constructed: 3 construction details. You may'also attach additional pages ifneeessa,
tar half ple Infectlon or non-vorer supple x,11,(ONLY wrh 1he acme corutnrclio...You can
euhoar onefrnt- St BNIITTAL INSTUCTIONS
9.Total well depth below land surface: 35 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
F,, ndnph,, //,In,a11 depths f,hffew(eramph-3n2tc) nd2o101) construction to the following.
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Il nit,
lJ timer level n aborc eo,tng.ate '- 1617 Mail Service Center,Raleigh,INC 27699-1617
11.Borehole diameter: 8.25 (in.) 24b. For Injection Well ONLY: In addition to sending the form to the address in
Hollow Stem Auger24aabove, also submit a copy of n this front within 30 days of completion of well
12.11'ell construction method: constmctlou to the following
(i e.auger,rotary,cable,direct toh,ere I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,INC 27699-1636
Method of test:13a.field(Rpm)
24c.For W atei Supply&Injection Wells:
. _
Also submit one copy of this toot within 30 days of completion of
13b.Disinfection type: -_ Amount well construction to the coumq health department of the county where
constructed.
Fon,,Gve-I Ninth Carolina De .",nentofFnvi,onmatt and Natu,alRcsomcu-D.vision of R'ete,Resoumn Revised August 2013