GW1-2021-00276_Well Construction - GW1_20210126

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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 FROM
ZONES
FROM TO DESCRIPTION
Well Contractor Name 5 ft- 17 ft. i i brown-gray silty clay
3270 A
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells LINER if a 'li`cable
FROM TO DIAMETER TOR HICKNESS MATERIAL
Geological Resources, Inc. ft. ft. in.
Company Name 16.iINNER CASING'OR IJBING "eotherinal;closed=tot; �!
WM0501419FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft• 2 rL 2" i" sch 40 PVC
List all applicable well permits(i.e.County,Stale, Variance,Injection,etc.)
ft. ft, in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 2 ft. 17 ft• 2 '"' 0.010 sch 40 PVC
ft. f. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT ;
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑bri ation 0 ft- 0.5 ft• Concrete Pour
Non-Water Supply Well:
2Monitoring ❑Recovery 0.5 ft 1.0 ft bentonite Pour
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.,SAND/GRAVEL PACK iCa` 'Wable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 1 ft. 17 ff ;Sand Pour
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)"
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type, min size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 0.5 ft. Concrete
01/06/2021 MW-12 0.5 ft- 10 ft. Gray silty clay
4.Date Well(s)Completed: Well ID# 10 ft- 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
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]at/long is sufficient)
36.274043 N 77.284546 W 01/08/2021
Signature of Certified Well Contractor! Date
6.Is are the wells: ©Permanent or ❑Tem
(are) pora ryt yi�iting this form,/hereby certify that the well(c)was(were)constructed in accordance
'-with 15A NCAC 01C.0100 or 15A NCAC 01C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONO b��"- copy oflhis record has been provided to the well owner.
Ifthis is a repair,fill out known well construction information and explain the natt_�re q(t rt71
repair under#11 remarks section or on the back oflhis form g
. J i-�N �L a Site diagram or additional well details:
You m y se the back of this page to provide additional well site details or well
8.Number of wells constructed: 1 >;G� onsZr"Cilo details. You may also attach additional pages if necessary.
Far multiple injection or non-water supply wells ONLY with the sant;b`fl'3 rile`r'iini yart ebmij"Oil
submitoneforn. °'v SUBMITTALINSTUCTIONS .
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 ifdiffierenl(example-3@200'and 1@100') construction to the following:
10.Static water level below top of casing: 12.21 (ft•) Division of Water Resources,Information Processing Unit,
/f water 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
II 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
m 13a.Yield
(gp ) Method of test: 24c.For Water Supply&Injection,Wells:'
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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