GW1-2021-00596_Well Construction - GW1_20211222

I
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Justin Radford 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 10.55 ft' 155 ft.
3270 A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER' a licable)
FROM TO DIAMETER THICKNESS MATERIAL
Geological Resources, Inc. ft. ft
Company Name 16.INNER CASING OR TUBING: eothermal closed-loop)
WM-0701255 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 5 it. 2 in• sch 40 1 PVC
List all applicable well permits(i.e.County,State,Variance,Injection,etc)
ft. ft. in.
3.Well Use(check well use): 7.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Pubbe 5 rL 15 ft' 2 1n. 0.010 soh 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 19.GROUT
FROM TO MATERIAL, EMPLACEMENT METHOD&AMOUNT
01rri ation 0 ft. 1 [t rout'
Non-Water Supply Well: 9 pour
EMonitoring ❑Recovery 1 ft- 4 fL bentonite pour
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 4 tt. 15 ft' �sand pour
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG attach additional sheets if necessa`
❑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 rt. 0.5 ft. Top soil
4.Date Well(s)Completed: Well ID#
10/27/2021 MW-8 0.5 ft. 5 ft. Brown medium sand
5 ft. 15 M Tan clay
5a.Well Location: it ft.
Holiday Food Mart 00-0-0000025052 ft ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
3 NC Hwy 32 N, Sunbury, NC 27979 u. ft. t f
Physical Address,City,and Zip
21.REMARKS
Gates 7908380110000
County Parcel Identification No.(PIN) J"
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification: l
(ifwell field,one tat/long is sufficient)
36.4415600 N 76.6100420 W a 12/1/2021
Signature of Certified Well Contractor Date
6.Is(are)the well(s): OPermanent 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 01C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or FINo copy of this record has been provided to the well owner.
Ifthis 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: 15 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if di,(jerent(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: unknown (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 Iniection Wells ONLY: In addition to sending the form to the address in
SO�Id flight auger 24aabove, also submit a copy o'f this form within 30 days of completion of well
12.Well construction method: Solid 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
24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test: 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