GW1-2202-00594_Well Construction - GW1_20221222

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Sam Bowers 14.WATERZOrEs „
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
3220-A
NC Well Contractor Certification Number 15.OUTER CASING for multi-ck§ed wells OR L RL 1f a"" tkbk ,r ��°
FROM TO DIAMETER THICKNESS MATERIAL
Geological Resources, Inc. ft. ft in.
16.INNER CASING OR TUBING l eothermifelosed-foo"
Company Name p FROM TO DIAMETER I THICKNESS MATERIAL
(�
2.Well Construction Permit#: ' `/„ 0 ft' 5 ft- 2 1D 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.SCREENfil
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5 rL 20 ft. 2 in. 0.010 sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
; ., lfr' �,
❑IndllstriaU 18.GROUT,COmmelCial ❑Residential Water Supply(shared) FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 ft. 2 ft. grout our
Non-Water Supply Well: p
2 ft. 4 ft bentonite pour
OMonitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/G1tAyEL PACK-if a` licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 4 ft. 20 tt' #2 sand pouf
❑Aquifer Test ❑Stormwater Drainage
ft. ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LDG attach additional sheets if necessa`
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillrock size,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 0.75 IL Concrete
4.Date Well(s)Completed: 09/20/21 Well ID#M W-3 0.75 ft- 12 ft. Dark brown silt
12 ft. 20 ft. Brown to tan silty clay
5a.Well Location: ft. ft.
Nics Pic Kwik #7 00-0-0000026088 ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
13700 Andrew Jackson Highway, Laurinburg, NC ft. ft.
Physical Address,City,and Zip
21.REMARKS
Scotland 010025 01018
County Parcel Identification No.(PII) DW SECT
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: + c ` s UiVI
(if well field,one lat/long is sufficient) QXAa-
22.Certification:
34.777775 N 79.488986 Wr 10/18/21
Signature of Certified Well Contractor Date
6.Is(are)the well(s): 2Permanent 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 FINo copy ofthis 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: 20 (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@100D construction to the following:
10.Static water level below top of casing: 13.01 (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: 6 (in.) 24b.For Infection Wells ONLY: In addition to sending the form to the address in
ii 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: 6 Solid Flight auger 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