GW1-2021-00598_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:
14.MAT ER ZONES777777 77 ��
Justin Radford FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
3270 A ft. ft.
NC Well Contractor Certification Number 1`S:OUTER"CASING for inulh caserhwetts'ORS INERT'if.a'licatile r`,,
FROM I TO DIAMETER THICKNESS MATERIAL
Geological Resources, Inc. ft. e. in.
Company Name ..c"N1NER EASING ORTQBIISG_ eofh'erival cl6sed=lba „_ K_,.. `
WM-0701255 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit th 0 ft. 5 R. 2 in. sch 40 PVC
List all applicable well permits(i.e.County,State, Variance,Injection,etc)
tt. ft. in.
3.Well Use(check well use): 7:SCRREN ,
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5 ft. 15 ft' 2 1n. 0.010 sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. f. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 4XB.GROUT,
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hri ation 0 rL 3 ft rout our
Non-Water Supply Well: 9 p
BMonitoring ❑Recovery 3 ft. 4 ft. bentonite pour
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAY,1wU1'AGTi ,f a licable,,, .,. s
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
4 ft• 15 ft• sand pour
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
2W.DRILUINGtL`OG;a'iiich,addifional sheetsdf=nec°essa ;` ,
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soit/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 0.5 tt Top soil
10/27/2021 MW-8 0.5 ft. 5 rt. Brown medium sand
4.Date Well(s)Completed: Well ID# 5 ft. 10 ft. Tan clay
5a.Well Location: 10 ft. 15 ft. Brown medium sand
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
Physical Address,City,and Zip 2I:RE114ARKS j r,F. �,_.
Gates 7908380110000
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: pt/y�,�.la S�TI
(if well field,one lat/long is sufficient) ll'c/"OrS.� Iry P-s*-f -ri$ING uryr
36.4415600 N 76.6100420 W 11/5/2021 ,vV
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 FIND 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 ofthisform. 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 oneform. 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 ifdifferent(example-3@200'and 2@100') 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
Solid flight au 24aabove, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Solid 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