GW1-2021-03323_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.
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
3270 A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING`for multi-cased wells OR LINER LINER;if applicable
FROM TO DIAMETERT THICKNESS I MATERIAL
Geological Resources, Inc. tt. ft. I in.
Company Name 16.INNER CASING OR TUBING +eotherma]closed-too
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft 10 ft. 2° 1 in. sch 40 PVC
List all applicable well perinits(i.e.County,Stale, Variance,byection,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 10 fit- 20 ft' 2 1n. 0.010 sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) f. f. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) t8.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 ft' 6 ft- Concrete Pour
Non-Water Supply Well: 6 ft- 8 ft. bentonite Pour
©Monitoring ❑Recovery
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 ft. ft.
❑Aquifer Test ❑Stormwater Drainage
$ ft. 20 ft. Sand Pour
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)_J 0 ft. 0.50 ft. Brown fine sand
02/15/2021 MW-2 0.50 rL 6 ft. Tan clayey sand
4.Date Well(s)Completed: Well ID# 6 ft, 20 ft. DPT; no recovery
5a.Well Location:
Speedway #8653 0-000036249 ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. q
1102 Kingold Blvd, Snow Hill, NC
Physical Address,City,and Zip 21.REMARKS /1' Li
Greene 0300260
County Parcel Identification No.(PIN) ViToce
R
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one lat/long is sufficient) A n _ �l�i
35.441778 N 77.661463 W `vj"� r� 02/17/2021
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the well(,)was(were)constricted 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 ENO copy ofthis 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 r21 remarks section or on the back ofthis for,i. 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: 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: 20 (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 easing: 12.84 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"=" 1617 Mail Service Center,Raleigh,NC 27699-1617
II.Borehole diameter: 3.5 (in.) 24b. For Infection Wells ONLY: In addition to sending the form to the address in
Direct Push 24aabove, also submit a copy of this form within 30 days of completion of well
11 Well construction method: 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:
i
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