GW1-2021-03315_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:
Justin Radford ,14.WATER.ZONES y,
FROM TO DESCRIPTION
Well Contractor Name ft ft. t
3270 A ft. ft.
NC Well Contractor Certification Number ,15;,OUTER CA Gfr mD ORIN a cable
FROM IN ' MATERIAL
Geological Resources, Inc. ft. ft. in.
Company Name /� 16.INNER CASING ORTUBING(geothermal closed-limp)
WM-0701240 FROM TO DIAMETER THICKNESS MATFnrsr.
2.Well Construction Permit#: 0 ft. 3 fa 2" i°• 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.SCREEN '
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 3 ft. 13 ft• 2 '"' 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 ft' 0 5 ft. Concrete Pour
Non-Water Supply Well:
©Monitoring ❑Recovery O 5 ft- ��� ft. � ,�
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERU L EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. • ft.
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 1 20..DRILLIN G ft is ft Sand Pour
G LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil rock shr,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft' 0.25 ft. Asphalt
01/07/2021 MW-2 0.25 ft• 0.75 fa Gravel
4.Date Well(s)Completed: Well ID#
0.75 ft. 3 fa Dark gray clay
5a.Well Location: 3 ft. 7 ft. Gray clay with silt
Gates Food Mart 0-00-0000015560 7 ft 13 ft. Gray fine sandy silt
Facility/Owner Name Facility ID#(if applicable) ft. ft.
3 US Highway 158 West, Gatesville, NC ft. ft RE k ;
Physical Address,City,and Zip 21.'REMARKS
Gates 6979-60-4533 3 2021
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Cc cation:
(if well field,one lat/long is sufficient) D%rVR Sedion
36.450011 N 76.699918 W m 1 o 7 202r
Signature £Certified Wel ontracto Date
6.Is(are)the well(s): ❑O Permanent or ❑Temporary By signing this form,1 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: ❑Yes or ONo copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 1 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 one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 13 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'a+nd 2@I00) construction to the following:
10.Static water level below top of casing:_ �J' 1 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
pp tl
11.Borehole diameter.• Y_ (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: 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
24c.For Water Supply&InjectionI ':Wells:
13a.Yield(gpm) Method of test: Also submit one copy of this fomi within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county liealth department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of WaterResources Revised August 2013