GW1-2021-00573_Well Construction - GW1_20211222

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: 4
Sam Bowers 14.WATER ZONES,
',
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
3220 A ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING for multi cased wells OR LINER ifa ticable
FROM I TO DIAMETER THICKNESS MATERIAL
Geological Resources, Inc. ft ft in
Company Name 16.INNER CASING OR TUBING "eother&sd closed"166
WM0601182 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 fL 2 ft. 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 I SLOT SIZE I THICKNESS_ MATERIAL
❑Agricultural ❑Municipal/Public 2 ft. 12 it' 2 "' 1 0.010 sch 40 PVC
❑Geothermal(Heating/Cooling Coolin Supply) ❑Residential Water Supply(single) ft. fa in.
� g/ g PP Y) PP Y( g )
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT-
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 0.5 it. Grout' Pour
Non-Water Supply Well:
0.5 ft 1.5 ft- Bentonite Pour
OMonitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL,PACK'if a` llc`able
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 1.5 ft. 12 ft. Sand
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG`attach addiHtinal aheets'af necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soWrock dze,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 fL 0.5 ft. Asphalt
4.Date Well(s)Completed: Well ID#
10/27/2021 MW-2 0•5 It. 5 ft. Dark brown sandy clay
5 ft. 7 ft. Tan/brown silty medium sand
5a.Well Location: 7 ft 9 ft. Tan medium sand
J ECO (J & J Texaco) 0-00-0000019342 9 fL 12 ft. Gr
Facility/Owner Name Facility ID#(if applicable) 1
ft. It.
610 Union Chapel Road, Pembroke, NC ft. It. 2 2021
Physical Address,City,and Zip 21.REMARKS; `
Robeson 9344-4037-4400 :SECrICM
County Parcel Identification No.(PIN) R1la(Jrli
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lavlong is sufficient)
34.686412 N 79.185758 W 10/29/21
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 1 SA NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 0No copy of this record has been provided to,the well owner.
1f 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: 12 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing:
7.45 Division of Water Resources,Information Processing Unit,
(ft.)
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells ONLY:j In addition to sending the form to the address in
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-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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