GW1-2021-05764_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:
Sam Bowers 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name y �O� ft• ft.
NC Well Contractor Certification Number ' 15.OUTER CASING for multi-cased wells OR LINER'if a,r Bcable
r1i(1t� FROM TO DIAMETER THICKNESS MATERIAL.
Geological Resources, Inc. r ;��• ;;;,`7, ft. ft. in.
Company Name 16JNNER CASING OR TUBING "eotherma[closed-loop)-
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft' 5 ft- 2 in. Soh 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 5 ft. 20 ft' 2 in. 0.010 soh 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
18.,GROUT
❑Industrial/Commercial ❑Residential Water Supply(shared) FROM TO `MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft' 0.5 ft- Grout Pour
Non-Water Supply Well:
BMonitoring ❑Recovery 0.5 ft 4 ft Bentoilite Pour
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19 SAND/GRAVEL PACK if a•"likable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
4 ft- 20 ft. Sand Pour
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessar
❑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 it- 0.5 ft. Asphalt
4.Date Well(s)Completed: Well 1])it
09/09/2021 MW-1 0•5 ft- 5 ft. Dark brown sand
5 ft. 10 ft' Light brown sand
5a.Well Location:
Kash N Karry 0-00-000034890 10 ft 15 ft. Light brown sand
15 20 Light brown sand
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
1003 East 4th Ave, Red Springs, NC ft. ft.
Physical Address,City,and Zip 21:REMARKS
Robeson 9358-0410-9044
County Parcel Identification No.(PN
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
34.804946 N 79.166008 W 10/11/21
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 BNo 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 farm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 20 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3@200'and 2@I00) construction to the following:
10.Static water level below top of casing: n/a (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
6" Solid Stem Au 24aabove, also submit a copy of this form within 30 days of completion of well
12.Well construction method: 9er 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