GW1-2021-00617_Well Construction - GW1_20210205

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Ronald F. Barron 14.-VATER10NES
Well Contractor Name FROM TO DESCRIPTION
2091-A fL ft.
fL ft �
NC Well Contractor Certification Number
15::OUTER.CASING`foriinul6 casedwells OR7INER'ifia hcable
Pidmont Industrial Services FROM TO DIAMETER THICKNESS MATERIAL
+3 ft 5 ft. 2' in. Sch 40 1 PVC
Company Name
.IN d6NER CASiNG:OR-TUBING eothermil El&id
NA
2.Well Construction Permit#• ' "/" " FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) fL ft. in.
3.Well Use(check well use): ft. ft. in.
:17:SCREEN_..s
Water Supply Well:
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural in,Municipal/Public 5 ft. 20 ft' 2 in. .010 Sch 40 PVC
J Geothermal(Heating/Cooling Supply) OI Residential Water Supply(single) ft. ft. in.:
73 Industrial/Commercial Residential Water Supply(shared)
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 1.5 fL 3.5 ft• 3/8 Bent.Chips Tfinlie
Monitoring ®Recovery 0 fL 1.5 ft- Concrete Mix Poured
Injection Well:
fL ft.
Aquifer Recharge ©Groundwater Remediation
`19:`SAND/GRAVELPACK'tf.a'"`hcable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ®Stormwater Drainage 3.5 fL 20 ft- #3 Filter Sand Trimie
Experimental Technology Subsidence Control fL ft.
Geothermal(Closed Loop) Tracer 20.0WLLING LOG-
Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soillrock type,grain size,etc.
0 fL 5 ft• grey silty sand
4.Date Well(s)Completed: 1-29-202� Well ID#GM-27 5 ft. 10 ft• reddish brown clayey sand
5a.Well Location: 10 ft. 20 ft- wet grey fine to course sand
Sampson Co. Disposal N/A fL ft. BT 20'
Facility/Owner Name Facility ID#(if applicable) ft. ft.
7434 Roseboro Hwy, Roseboro, 28382 fL rt.
Physical Address,City,and Zip ft. ft.
Sampson N/A 2L REMARKS
County Parcel Identification No.(PIN) Methane Gas monitoring;well. Well set w/above ground
casing, concrete pad, lock, tag, ID#.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
34 58.3568' N 78 27.5385' W x�c�- 2-2-2021
6.Is(are)the well(s) XI Permanent or E Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or XX No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If This is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:N/A i 9
R E C 9 VE D SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 0 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierem(example-3 a@200rdiT @X0'�- 2021 CODStTUCtIOn t0 the following:
10.Static water level below top of casing: 141+ II `DD (ft.) Division of Water Resources,Information Processing Unit,
ifwaterlevel is above casing,use information Processing Unit 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 10 (•n), DWR Section
24b.For Infection Wells: In addition to sending the form to the address in 24a
Auger above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 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&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction toRthe county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources` Revised 2-22-2016