GW1-2021-05612_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
FR:wATERZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
3270A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER i.a llcable
FROM TO DIAMETER THICKNESS MATERIAL
Geological Resources, Inc. ft. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-too
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 3 fi' 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 MATERGI
❑Agricultural ❑Municipal/Public 3 ft' 13 ft' 2 in. 0.010 sch 40 PVC
[]Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft• in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hri ation 0 ft' 0.5 ft. Grout Pour
Non-Water Supply Well:
OMonitoring ❑Recovery 0,Cj
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 i ft. ft.
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology 13 Subsidence Control 2 ft' 13 ft. Sand Pour
20.DRILLING LOG attach additional sheets d necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soilfrock size,eta
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 fL 13 & Direct push-no cuttings retained
4.Date Well 08/09/2021 MW-1 ft. ft.
$)Completed: Well ID# ft. ft.
5a.Well Location: ft. ft.
King Mart 0-00-000013263
Facility/Owner Name Facility ID#(if applicable) +a.
ft. ft.
4537 NC Highway 11 , Grifton, NC ft. ft.
Physical Address,City,and Zip 21.REMARKS`;
Lenoir 455700087679 r�
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22. rtification:
(if well field,one lat/long is sufficient)
35.330952 N 77.488837 W too i1 - 09/09/2021
Si ofCe ifiedWel Cc tractor Date
6.Is(are)the well(s): 2Permanent or ❑Temporary By Jkning this form,I here y certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or l5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo 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: 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: 13 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dif ferent(example-3Q200'and 2@100D construction to the following:
10.Static water level below top of casing: 4.91 (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 (in.) 24b.For Iniection Wells ONLY: hi 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
12.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
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