GW1-2021-03296_Well Construction - GW1_20210603

WELL CONSTRUCTION RECORD For Intemal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Justin Radford FR•"`ATERZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
3270 A ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
FROM TO DWMETER 'THICKNESS MATERIAL
Geological Resources, Inc. ft. ft. in.
Company Name 16.INNER CASING OR TUBING "eothermal closed-loop)
FROM TO I DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 fa 2 R. 2" In• sch 40 PVC
Lisl 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 2 ft' 12 ft' 2 in. 0.010 sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial El 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:
RMonitoring ❑Recovery 0.5 rt 1 ft Bentonite Pour
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
1 rt. 12 rt. Sand POUT
❑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) 0 ft- 12 rt. Direct Push; no recovery
ft. ft.
4.Date Well 02/02/2021 MW-1s)Completed: Well ID# ft. ft.
5a.Well Location:
Speedway #8656 0-0000036342 ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
207 N X Powell Blvd, Whiteville, NC ft. information Processing unif
Physical Address,City,and Zip 21.REMARKS Cdoll
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 fat/long is sufficient)
34.331105 N 78.708555 W �� 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(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 ofihis 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 rentarkc section or on the back of this forin. 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 saute 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
For multiple wells list all depths if dtffercm(example-3 a 200'and 2@ 100') construction to the following:
I
10.Static water level below top of casing: ~7.5 (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: 3.5 (in.) 24b. For Infection Wells ONLY: In addition to sending the form to the address in
Direct1•�push 24aabove, also submit a copy of this form within 30 days of completion of well
12.Well construction method: N construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
L13a.
ATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
24c.For Water Supply&Injection Wells:
eld(gpm) Method of test: Also submit one copy of this form within 30 days of completion of
isinfection 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