GW1-2021-00274_Well Construction - GW1_20210126

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: ;
Justin Radford 14.
FROM WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 5 rL 17 ft. brown-gray silty clay
3270 A
NC Well Contractor Certification Number 15.OUTER CASING for Multi-cased wells OR LINER;if.a livable
FROM TO DIAMETER THICKNESS MATERIAL
Geological Resources, Inc. ft. ft. in.
Company Name 16.INNEWCASING,ORTUBING eothermA closed-loop) -s
WM0501419FROM TO I DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit it: 0 ft. 2 ft. 2" i"• SCh 40 PVC
List all applicable well permits(i.e.County,State, Variance,Injection,etc.)
ft. ft. I in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 2 rL 17 rL 2 in. 0.010 SCh 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.=GROUT:
( w;
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 rL 0.5 ft- Concrete Pour
Non-Water Supply Well:
OMonitoring ❑Recovery 0.5 rt• 1.0 Bentonite Pour
rt•
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVELPACK if,a livable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 1 ft. 17 ft• ;Sand Pour
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20,DRILLING LOG a"tta'ch additional sheetsiif necessag
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillrock type,grain size,etc.
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) 0 ft. 0.5 ft. Concrete
4.Date Well(s)Completed: 01/06/2021 Well ID#MW-1 1 0.5 ft. 10 ft. Gray silty clay
10 rL 17 ft. Brown silty clay
5a.Well Location:
RAM #9 0-00-0000026624
Facility/Owner Name Facility ID#(if applicable) ft. ft.
100 West Jackson Street, Rich Square, NC ft. ft.
Physical Address,City,and Zip 21.REMARKS
Northampton 5902-53-6084
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one lat/long is sufficient)
36.274043 N 77.284546 W 01/08/2021
Signature of Certified Well Contractor Date
6.Is(are)the well(s): 2Permanent or ❑Temporary signing this form,l hereby certify That the we/l(s)was(were)constructed in accordance
S-Ni
ivj!h l SA NCAC 02C.0100 or LSA NCA C 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNtT j � copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and ex�laili ihe,aIure of the
repair tinder#21 remarks section or on the back of this•form. n 223.Site diagram or additional well details:
IrNZO"You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: ;cotns'thlcl:ion details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construptiott)tou can
submit one form.
"t'=+ t'OAUBMITTALINSTUCTIONS
ly,,;,. ��r; ;,�•, '
9.Total well depth below land surface: 17 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifoli ferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 6.70 (ft,) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b. For Infection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: 6"
Steel Flight Auger 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
(gP ) 24c.For Water Supply&Injection Wells.
m 13a.Yield Method of test:
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-I North Carolina Department of Environment and Natural Resources-Division of Water,Resources Revised August 2013