GW1-2021-00565_Well Construction - GW1_20211222

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Justin Radford ia:,vATERzoNEs r> fi
Well Contractor Name FROM TO DESCRIPTION
3270-A 9 fL 15 f`' gray medium sand
ft. ft.
NC Well Contractor Certification Number
S.OUTLR CASING`for,inultrca`sedvr`'ells ORLINER if a licatile ,
Geological Resources, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name
0 f` 5 t` 2 '" SCh 40 PVC
WM07012646INNER"GASINGGOR'=TUBING eothe�malcloseil==lo`o` s
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL \
List all applicable well construction permits(i.e.UIC,County,Stale, Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well• ? SCREEN.. x :r <
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ®Municipal/Public 5 f`' 15 f`' 2 '"' 0.010 IsCh 40 JPVC
Geothermal(Heating/Cooling Supply) 13Residential Water Supply(single) ft. ft. in.
Industrial/Commercial 13Residential Water Supply(shared) 1gaGROUT _
Irrl ation FROM TO ~MATERIAL ~EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 f` 3 f` cement pour
x Monitoring ®Recovery 3 ft- 4 ft* bentoliite pour
Injection Well: ft. fa
RJUAquifer Recharge ®Groundwater Remediation
19.FSAND/GRAVEL PACK(if a`licab7e X
Aquifer Storage and Recovery [3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stotmwater Drainage 4 ft 15 ft Sand pour
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20:YDRItiLINGT 6G"at ach ailditionalsheefs t;neces"ss 201 x,
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,gmin size,etc.
0 f` 2 t` tan medium sand
4.Date Well(s)Completed.11/18/2021 well ID#MW-1 2 ft. 6 ft. black clay _
5a.Well Location: 6 9 R. -gray! la
WeyerhauserPropertyDieselSpill-Country Mart N/A 9 ft. 15 tt gray medium sa
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Saintsville Road, Greenville, NC 27834 ft. ft. , ,_ ,;J-...
Physical Address,City,and Zip ft. ft. i� aC�T1(w!;w,nrr nit lr(iA
Pitt 4771757268 21:REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Iat/long is sufficient) 22.Certification:
35.725026 N 78.77434588 W �
11/18/2021
6.Is(are)the well(s)IDPermanent or Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or Jallo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under 921 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:1 SUBMITTAL INSTRUCTIONS'
9.Total well depth below land surface: 15 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
I,or multiple wells list all depths ifdii ferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing:—8 (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:6tt (in.) 24b. For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: Auger above, also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
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& Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016