GW1-2021-03297_Well Construction - GW1_20210603

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES "k"
Justin Radford FROM TO DESCRIPTION
Well Contractor Name
3270 A fL ft.
NC Well Contractor Certification Number .15.OUTER CASING for lti-cA-§6d,'Welh) LINER if applicable
tA )I
FROM TO TuDMETER -OF!TiiIC THICKNESS I MATERIAL
Geological Resources, Inc. ft. ft. I , in. I I
Company Name 16.INNER CASING OR 2IIBING-Wothermal,closed-lbop):
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 2 ft. 12" in. SCh 40 PVC
List all applicable well permits(i.e.County,State, Variance,Injection,etc) ft. ft. in-
3.Well Use(check well use):
17.SCREENA
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural EiMunicipal/Public 2 ft. 12 ft 2 in. 0.010 sch 40 PVC
OGeothermal(Heating/Cooling Supply) [DResidential Water, Supply(single) in.
DIndustrial/Commercial 0 Residential Water Supply(shared) ,,18.GROUT,"",
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ElIrrigation 0 ft. 0.5 ft- Condete Pour
Non-Water Supply Well: 0.5 Bento I nite Pour
EMonitoring 0 Recovery
Injection Well:
0Aquifer Recharge 0 Groundwater Remediation "'..19.SANDIGRAXEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
ElAquifer Storage and Recovery 0 Salinity Barrier ft. ft. I
0 Aquifer Test DStormwater Drainage 1 12 Sand I Pour
oExperimental Technology El Subsidence Control 1 20.DRILLING LOG attach additional sheets if necessary)
DGeothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
OGeothermal(Heating/Cooling Retum) 00ther(explain under#21 Remarks) 0 ft- 12 ft. Direct Push; no recovery
4.Date Well Completed: 02/02/2021 Well ID#MW-1
5a.Well Location: ft. ft. ED
Speedway #8656 0-0000036342
Facility/Owner Name Facility 1134(if applicable) ft. ft. jUN X 3 2021
207 N X Powell Blvd, Whiteville, NC ft. ft. Information Processing unit
Physical Address,City,and Zip 2L REMARKS'-
UVVK Ovy
Columbus 0281.04-71-9641
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)
34.331105 N78.708555 W 02/17/2021
Signature ot'Certified Well Contractor Date
6.Is(are)the well(s): [OPermanent or oTemporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: OYes or EI No copy ofthis record has been provided to the well owner.
Ifthis is a repair,fill out known well construction information and explain the nature ofthe
repair under'_21 remarks section or on the back ofthisforni. 23.Site diagram or additional well details:
1 You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 12 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
ror multiple wells list all depths iidififerent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: -7.5 (ft.) Division of Water Resources,Information Processing Unit,
I(waier level is above casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 3.5 (in.) 24b. For Iniection 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: Direct push 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&Injection Wells:
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