GW1-2202-00591_Well Construction - GW1_20221222

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.Sam Bowers FROM ER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
3220-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cesed wells OR LINER;l d `ticable
FROM TO DIAMETER THICKNESS MATERIAL
Geological Resources, Inc. 0 ft. 30 ft 4 i° 1 sch 40 1 PVC
Company Name 16.'INNER CASING OR TUBING "eoihermal,closed-loo
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: N/A 0 ft• 40 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 SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 40 fi' 45 ft 2 in. 0.010 sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fi' ft in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT_ '
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 ft' 37 ft grout pour
Non-Water Supply Well:
37 ft 39 ft. bentonite pour
SMonitoring ❑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 ft. ft
❑Aquifer Test ❑Stormwater Drainage 39 45 #2 sand pour
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG tittah additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardnes sofl/mck type,grain size,eta
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks 0 ft- 0.25 it- Asphalt
4.Date Well(s)Completed: 09/21/2021 Well ID#TW-1 0.25 ft. 1 ft. Light brown sand
1 fL 20 ft. Dark brown to gray silt
5a.Well Location: 20 ft 26 ft. Gray sand
Nics Pic Kwik #7 00-0-0000026088 26 ft. 3o ft. Gray clay
Facility/Owner Name Facility ID#(if applicable) 30 fi- 38 ft Gray to tan sandy clay
13700 Andrew Jackson Highway, Laurinburg, NC 38 ft. 45 ft , ,
Physical Address,City,and Zip 21.REMARKS "
Scotland 010025 01018cs
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County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: `1FA1Tlff�f�, S4ri�i UNI'
22.Certification:
(if well field,one lat/long is sufficient)
34.777775 N 79.488986 W 10/18/21
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 1 SA NCAC 02C.0100 or I5A 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:45 (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@100) construction to the following:
10.Static water level below top of casing: 14.77 (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: 4.5 (in.) 24b.For Iniection Wells ONLY- In addition to sending the form to the address in
Hollow stem/Mud rota 24aabove, also submit a copy of this form within 30 days of completion of well
12.Well construction method: ry 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 fbirm 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