GW1-2021-00597_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:
Justin Radford 14.WATER ZONEs
FROM TO DESCRIPTION
Well Contractor Name 11.10 ft' 15 ft.
3270 A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER a `Ocable
FROM TO DIAMETER THICKNESS MATERIAL
Geological Resources, Inc. ft I ft in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-lboul
WM-0701255 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 5 fL 2 tn. 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 5 ft 15 ft 2 in. 0.010 sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. In.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hri ation 0 it. 1 ft grout pour
Non-Water Supply Well:
I7Monitoring ❑Recovery 1 ft. 4 ft. bentonite pour
Injection Well: fL ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if s 'licable
❑Aquifer Storage and Recovery ❑Salinity Barrier 4 rt.FROM TO ft. MATERIAL EMPLACEMENT METHOD
sand pour
❑Aquifer Test ❑Stormwater Drainage 15
ft. ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG attach additional sheets if necessary)'
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION color,hardness,soiUrock type,Erain size,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 0.5 ft. Top soil
4.Date Well(s)Completed: Well ID#
10/27/2021 MW-7 0.5 ft. 5 ft. Medium brown sand
5 ft. 15 ft. Ta:
5a.Well Location:
ft. ft.
Holiday Food Mart 00-0-0000025052 ft. ft EC n
Facility/Owner Name Facility ID#(if applicable)
3 NC Hwy 32 N, Sunbury, NC 27979 ft ft
ft. ft. V
Physical Address,City,and Zip 21.REMARKS
Gates 7908380110000
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one lat/long is sufficient) G
36.4415600 N 76.6100420 W O 12/1/2021
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 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 E]No 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
S.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 dierent(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 Infection Wells ONLY: In addition to sending the form to the address in
Soled fll ht au 24aabove, also submit a copy of this form within 30 days of completion of well
12.Well construction method: g ger 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