GW1-2021-05595_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 �-
a 14.WATER ZONES
`�� g Y � � FROM TO DESCRIPTION
Well Contractor Name
1 °Sly 15.OUTER CASING for mu1H-cased
3270 A
NC Well Contractor Certification Number COOE�r'tIF' , wells OR LINER°if !cable
1� JI�O.tI FROM TO DIAMETER TRICIQdESS MATERIAL.
Geological Resources, Inc. t�i7��'` p;��C? ft. ft. in.
Company Name 16.INNER CASING OR TUBING'(geothermal closed-loop)
WM-0701250 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft' 3 tt. 2 in. 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 tt. 8 ft' 2 in. 0.010 sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hri ation 0 fa 0.5 ft. Grout Pour
Non-Water Supply Well:
0.5 ft. 2 ft- BentonitePour
2Monitoring ❑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 2 ft. 8 ft. Sand Pour
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessa'
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/mck type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. g ft. DPT; no recovery
4.Date Well 07/21/2021 GMW-1 ft. ft.
Completed: Well ID# ft. ft.
5a.Well Location: ft. ft.
Duck Thru Food Mart#29 00-0-0000035738 ft ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
512 Caratoke Highway, Moyock, NC
ft. ft.
Physical Address,City,and Zip 21.REMARKS
Currituck 9A-720000 4.
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one Iattlong is sufficient)
36.52498 N 76.178706 W 07/23/2021
Signature of Certified Well Contractor Date
6.Is(are)the well(s): 21'ermanent 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 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: 8 (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 1@I00) construction to the following:
10.Static water level below top of casing: 1 .60 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 3.5 (in.) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
Direct U$h 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
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