GW1-2021-00277_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.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 5 R. 17 ft' I brown-gray silty clay
3270 A ft. ft. I
NC Well Contractor Certification Number IS:OUTER CASING for mulfi-cased wells OR'LINER,'if a lica6le
FROM TO DIAMETER }THICKNESS MATERIAL
Geological Resources, Inc. ft. ft. in.
Company Name 16.INNER CASING�OR- BING eothermal closed-loo"
WM0501419FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 2 ft. 2" in sch 40 PVC
List all applicable well permits(i.e.County,State, Variance,Injection,etc)
in.
3.Well Use(check well use):
,17.SCREEN r
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 2 ft' 17 ft. 2 1O 0.010 SCh 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water,Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 rt. 0.5 ft. Concrete Pour
Non-Water Supply Well:
17Monitoring ❑Recovery 0.5 ft. 1 ft. bentonite . Pour
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.:SAND/GRAVELPACK°if a' Ii"cable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 1 rt. 17 ft. Sand Pour
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
30.DRILLING UOG attacfi additional sheetsif necessa''
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,gnin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)_j 0 R• 0.5 ft• Concrete
01/06/2021 MW-13 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: ^ 0
(if well field,one lat/long is sufficient) `OJT
36.274043 N 77.284546 W 01/08/2021
Signature of Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certify that the wel/(s) was(were)constricted in accordance
with 15A NCAC 02C.0100 or 1 JA NCAC'02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or BNo a^ p ofthis record has been provided to the well owner.
If this is a repair,fill out known well construction information and expl m rhrnhturi1pf the
repair under 921 remarks section or on the back of This form. '�a' .� 23.Site diagram or additional well details:
n u may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 1 1 N 2 Zvnstruction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same cons t on,you can
submit one form. , r,;,•SUBMhI TAL INSTUCTIONS
9.Total well depth below land surface: 7 tiinv r�{iY.) "�4a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 tt 200'and 2@100') construction to the following:
10.Static water level below top of casing: 15.72 (ft•) Division of Water Resources,Information Processing Unit,
if water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: ,� (in.) g
6 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• 6II 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
i
m 13a.Yield
(gp ) Method of test: �;W 24c.For Water Supply&Injection ells(
,
Also submit one copy of this formr within 30 days of completion 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 and Natural Resources-Division of Water Resources Revised August 2013