GW1-2021-05592_Well Construction - GW1_20211015

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
FROM TO DESCRIPTION
Well Contractor Name ft ft
3270A ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-eased wells OR•L'1NER+ a 'livable
FROM TO DIAMETER THICKNESS MATERIAL
Geological Resources, Inc. ft. ft In.
Company Name 16.INNER CASING OR TUBING(eothermal closed-loo'
FROM TO DIAMETER THICKNESS I MATERIAL
2.Well Construction Permit#: 0 s. 2 ft. 2 in sch 40 PVC
List all applicable well permits(i.e.County,State,Variance,Injection,etc) ft. ft.
3.Well Use(check well use): 11 SCREEN,
Water Supply Well: FROM TO I DIAMETER I SLOT SIZE I THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 2 ft 10 ft 2 m' 1 0.010 sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fL ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18,GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0
Non-Water Supply Well: ft' 0.5 tt Grout Pour
I7Monitoring ❑Recovery 0.5 ft. 1 fL Bentonite Pour
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if it livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD1 ft. 12 it. Sand Pour
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control ltl.DRILLING;LOG'attach ailditlonsl sheets'if:neee8aa` ' .,.
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,harde soil/rock tym v1du size,eta
❑Geothermal(Heating/Cooling Return) ❑Other(e lain under#21 Remarks) 0 ft. 12 ft. Direct push;no Iithology
08/18/21 GMW-1 ft. ft.
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location:
ft. ft. •��a
Handy Mart #59 7-030-1-129
Facility/Owner Name Facility 1D#(if applicable) q `b
ft. ft. `s �c�-a•
3990 US Highway 70 E, New Bern, NC fL ft OC
Physical Address,City,and Zip
21.REMARKS
Craven 7934-66-5266 -
�.C'6l
fi011'' n to �c(y`011
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)
35.038672 N 77.006607 W 08/20/21
Signature of Certified Well Contractor Date
6.Is(are)the well(s): la Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with I5A NCAC 02C.0100 or 1 SA 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 to the well owner.
Ifthis 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 wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple innjection 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 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dii erent(example-3@200'and 2@I00) construction to the following:
10.Static water level below top of casing: 2.27 (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: 2 (in.) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
Direct nu$I I 24aabove, 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
24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test: 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