GW1-2021-00627_Well Construction - GW1_20210326

WELL CONSTRUCTION RECORD For Internal Dae ONI.y:
This form can be used for single or multiple wells
1.Well Contractor Information:
Jonathan R. Grubbs 14.WATER ZONES
FROJI TO DESCRIPTION
Nell Contractor Name ft ft
3001 ft. fL
NC Well Contractor Certification Number 15.017TERCASING formulti-e sedwells OR LINER da Gta fe
FROM TO DLkMETER THICKNESS MATERIAL
Terraquest Environmental Consultants, P.C. ft. ft. I in.
Company Name 16.INNER CASING OR TUBING eolhermal dosed-Ino
FROM TO DIAMETER THICKNESSI MATERIAL
2.Well Construction Permit N: ft. ft I ,n.
List all applicable well permits o 1,('pang,,Since, Yarlanee,Iryenlon,eral
ft. ft in.
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 20 (t 25 It 1 in. .010 SCh.40 PVC
❑Geothermal(Heating/Cooling Supply) El Residential Water Supply(Single) ft A in.
❑Industrial/Commercial ❑Residential Water Supply(shared) I&GROUT .-
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lul anon 0 R' 16 0- Portland Pour
Non-Water Supply Well:
Gs Monitoring ❑l2ecavew 16 It 18 R Bentonite POUT
Injection Well: ft. I f.
❑Aquifer Recharge ❑Groundwater Remedialion 19.SAND/GRAVEL PACK , eippl'vabit
FROMTO MATERIAL EMPLACEMENTMETHOO 18b. �❑Aquifer Storage and Recovery ❑Salinity Barrier
5 « No.2 Sand Pour
[I Aquifer Test ❑SlormHaler Drainage
ft. It
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG atmrh addidmal sheets if taw
❑Geodlermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION orlon Inca a eoill.&qps,ecti.it.,eta.
❑Geotherrnal(Heatin Conlin Return) ❑Other(exlain under 421 Remarks) 0 ft' 0.25 ft Asphalt
4.Date Wells)Completed:
3/9/2021 Well IDq ASP2-ASP4-ASP6 0.25 f` 20 IL Sandy Lean Clay(CL)
20 rt. 25 a Clayey Sand(SC)
5a.Well Location: ft. ft.
Poco#1 Parnell Oil Comp. 0-021993 m rL
Facility/Owner Name Facility IDk(if applicable)
ft. ft.
97 N. Fayetteville St. Parkton NC 28371 ft. rL 2 6 2
021
Physical Address,City,and Zip 21 REMARKS
Robeson 949169844900
County Parcel Identification NO.(PIN)
Sh.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
afwell field,one falling is sufficient)
34.9026 N 78.0105 N :.�6 ecds _ ..., 3/24/2021
Signature of Certified Well Contractor Date
6.Is(are)thewell(s): MPermaoent or ❑Temporary
., .crgntng this form /100 or 5A M that the .0206J was/onno-consmmad in and that
ace
xarh 6A NCAC 02( .0[Oo or[SA NCAC'02C.0206 Well Constnmuon Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy of this record has been provided to the well owner.
/f this is a repair fill out known well construction infi nnaaon and euplam the nature of the
repair under d21 remarks section or on the back of this 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: 3 construction details. You may also attach additional pages if necessay.
Rv ma[tiple iryection m non-water supply we/[s ONLY m irb the some conshu.nrnr,ymrcan
whim,one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 25 24a. For .All Wells: Submit this form within 30 days of completion of well
Formaltiple.,Hsho.11deprh,ddiff,,,afex,eii 3@200'and2d100F construction to the following.
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
/{„--arerlerel is ab......... use"- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8.25 (in.) 24b. For Infection Well ONLY: In addition to sending the form to the address in
Hollow Stem Au 24a above, also submit a copy of this form within 30 days of completion of well
12.%N ell construction method: Auger construction to the following'.
(i.e.auger,rotary,cable,direct push.etc.)
Division of Water Resources,Underground Injection Control Program,
FOR NVATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
Ids.Yield m Method of test:_ 24c.For IN Supply&Infection Wells:
(SP ) Also submit one copy of this form within 30 days ofcompletion 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 mid Natural Resources-Division of Water Resources Raised August 2013