GW1-2022-01696_Well Construction - GW1_20220131

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZO
Sam Bowers FROM TONES DESCRIPTION
Well Contractor Name ft.
3220 A
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR LINE apycable)
FROM TO DIAMETER TTHCKNESS MATERIAL
Geological Resources, Inc. ft. ft. : in. I
Company Name 16.INNER CASING OR TUBING(keother al closed-loop)'_'_'_
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft 15 2 in. sch 40 PVC
List all applicable well permits(i.e.County,State,Variance,Injection,etc) in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural OMunicipal/Pubfic 15 ft' 30 ft' 2 in. 0.010 Soh 40 PVC
DGeothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
01ndustrial/Commercial OResidential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
0 Irrigation 0 ft' 12 ft- Grout Pour
Non-Water Supply Well:
©Monitoring ORecovery 12 ft. 14 ft. B Pour
Injection Well:
0 Aquifer Recharge OGroundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
OAquifer Storage and Recovery 0 Salinity Barrier
14 30 Sand Pour
ElAquifer Test El Stormwater Drainage
ClExperimental Technology D Subsidence Control Sand
20.DRILLING LOG(attach additional sheets if necessary)
DGeothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soil/rock siz etc.)
DGeothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) 0 0.5 Concrete
4.Date Well(s)Completed: 12/14/21 Red silt
Well El)#MW-10 0.5 15
15 ft- 25 ft. Red medium sand
5a.Well Location:
Daniel's Exxon 0-0009918
Facility/Owner Name Facility H)#(if applicable) ft. JAN 3 1 2027
115 East Central Avenue, Raeford, NC
Physical Address,City,and Zip 14
21.REMARKS
Hoke 6943-4100-1019
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if
field,one lattlong is sufficient)
34.9787508 N79.2231948 W 12/17/2021
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or OTemporary 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: OYes or E]No 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:
1 You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 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: 30 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@100) construction to the following:
10.Static water level below top of casing: unknown -(ft) Division of Water Resources,Information Processing Unit,
Ifwuter level is above casing,use"+" 1617 Mail Service Center,
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
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Solid flight auger construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) Division of Water Resource S,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service i Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test. 24c.For Water Supply&Injection Wells:I
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-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013