GW1-2021-00660_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 r
FROM TO DESCRIPTION
Well Contractor Name
3270 A fa fL
NC Well Contractor Certification Number 15.OUTER CASING for multi-caeed'wells OR LINER" a "`lleable
FROM TO DIAMETER THICKNESS MATERIAL
Geological Resources, Inc. ft. ft. In.
Company Name 16.INNER CASING OR TUBING eothermai dosed4bbl
FROM TO DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit#: ft ft, in
0 10 2 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 DL►ME!ERto.01(OT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 10 & 25 ft• 2 sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hri ation 0 fa 5 ft• grout pour
Non-Water Supply Well:
EMonitoring ❑Recovery 5 rt. g it. bentonite pour
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL, EMPLACEMENT METHOD9 ft- 25 ft. ' Sand pour
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG attach.additi6iud sheets If necesijk
yl-
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soiltrock Woe,grain sirA etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 0.5 ft. Gravel
10/28/2021 MW-1 0.5 ft- 15 % Backfill
4.Date Well(s)Completed: Well ID# 15 it- 25 ft. Brown Silt
5a.Well Location: % fA
Henderson Food Mart 00-0-0000005987 ft. ft.
Facility/Owner Name Facility ID#(if applicable)h
ft. ft 4 n "�1 s
420 E Andrews Ave, Henderson, NC 27536
Physical Address,City,and Zip
Vance 0073 02002 31:REMARK3
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)
36.3275950 N 78.3950230 W 12/07/2021
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 ISA NCAC 02C.0100 or ISA NCAC 02C.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 ojthe
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: 25 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ijdijferent(example-3@2200'and 2@100) construction to the following:
10.Static water level below top of casing: 16.80 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
i
11.Borehole diameter: 6 (in.) 24b.For Infection Wells ONLY: In addition to sending the form to the address in
Sol id ht auger 24aabove, also submit a copy of this form within 30 days of completion of well
I
12.Well construction method: 9 9 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
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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