GW1-2021-02381_Well Construction - GW1_20210601

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This foam can be used for single or multiple wells
1.Well Contractor Information:
Justin Radford 14.WATER ZONES
FROM TO DESCRIMON
Well Contractor Name ft. ft.
3270 A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)`OR LINER if a Iicable
FROM TO DIAMETER THICKNESS MATERIAL
Geological Resources, Inc. ft. ft. in.
Company Name 16.INNER CASINGOR TUBING'"eothermal closed-loo'
WM0701244 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 2 ft. 2 ID sch 40 PVC
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. ft. ht
3.Well Use(check well use): 17.SCREEN s:
Water Supply Well: FROM TO DIAMETER SLOT SIZE TBICKNESS IMATERIAL
❑Agricultural ❑Municipal/Public 2 fi- 12 It' 2 In. 0.010 sch Q7 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT 1l;
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 0.5 ft- Grout
Non-Water Supply Well:
OMonitoring ❑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 0.5 ft. 1 it. Bentonite
❑Aquifer Test ❑Stormwater Drainage
Sand
-20.DRILLING LOG(attach additio
❑Experimental Technology ❑Subsidence Control " sheets'if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,roll/rock type,gran s etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 12 ft. DPT;no recovery
04/28/21 MW-4R ft. ft. I
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location: ft. ft.
Sligo Citgo 0-0000033554 ft.
Facility/Owner Name Facility ID#(if applicable) Plucessing
2152 Caratoke Highway, .
NC ft ft intcrma�n
ft. ft
Physical Address,City,and Zip
"21.REMARKS:
Currituck 003-200000-620000
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
36.4527 N 76.077744 W 05/19/21
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 E]No copy of this record has been provided t0 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: 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: 12 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'and 2@I00) construction to the following:
10.Static water level below top of casing: 2.47 (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
D i reef $h 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: P 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 fbr 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