GW1-2021-03317_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 FR WATER ZONES
ROM TO DESCRIPTION
Well Contractor Name ft. ft.
3270 A
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if s` licable
FROM TO DIAMETER THICKNESS MATERIAL
Geological Resources, Inc. ft. I ft in.
Company Name 16.INNER CASING OR TUBING geothermal closed-loop)
WM-0701240 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft' 3 it. 2° 1°' 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 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
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 it. 0.5 rt. Concrete Pour
Non-Water Supply Well: ft. - 0 ft.
©Monitoring ❑Recovery 0,5 &A, _
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 1 ft. ft.
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology OSubsidence Control 1 tt 3 ft. Sand Pour
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardnes softock s' etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks 0 ft' 0.25 ft. Asphalt
01/07/2021 MW-5 0.25 ft 0.75 fL Gravel
4.Date Well(s)Completed: Well ID#
0.75 ft- 3 ft. Dark gray clay
5a.Well Location:
Gates Food Mart 0-00-0000015560 3 ft. 7 ft. Gray clay with silt
7 f° 13 ft. Gray fine sandy silt
Facility/Owner Name Facility ID#(if applicable) ft. ft
3 US Highway 158 West, Gatesville, NC
ft. ft J 1 V U,.�
Physical Address,City,and Zip
21.REMARKS
Gates 6979-60-4533 JUN X, 93 2021
County Parcel Identification No.(PIN)
si1 Unit
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: i ao��' d ,'g0i1
(ifwell field,one lat/long is sufficient)
36.450011 N 76.699918 W oi o7 az�
Signature Certified Well Coy actor Date
6.Is(are)the well(s): ®Permanent or ❑Temporary By signing this form,I hereby certtfy 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 ElNo 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 ifdifferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 32 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
�11
11.Borehole diamete•• (in.) 24b.For Infection Wells ONLY In addition to sending the form to the address in
6" Steel Flight Au 24aabove, also submit a copy of this form within 30 days of completion of well
12.Well construction method: 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
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-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013