GW1-2022-01704_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 ZONES
Sam Bowers FROM TO DESCRIPTION
Well Contractor Name ft. ft.
3220 A
NC Well Contractor Certification Number 15.OUTER CASING for multi casedwells OR LINER ii` liesble
FROM TO DIAMETER T�CKNESS MATERIAL
Geological Resources, Inc. ft. ft. I I in.
Company Name 16.INNER CASING OR;TUBING eothermalscldse&166
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft 5 ft 2 in. 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' 20 ft• 2 in. 0.010 sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water SuPP1Y(single) ft ft' in.
❑Industrial/Commercial ❑Residential Water Supply(shared) z 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 2 ft Grout Pour
Non-Water Supply Well:
OMonitoring ❑Recovery 2 ft 4 Bentonite Pour
ft
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a li6ble
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 4 ft 20 ft Sand Pour
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology El Subsidence Control
20.DRILLING LOG attach=addHiohal shee'ts'if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,gntin size,etc
❑Geothermal (Heating/Cooling Return ❑Other(explain under#21 Remarks 0 ft' 1 ft. Top soil
4.Date Well(s)Completed: Well lD#
10/28/2021 GMW-1 1 ft' 4 ft. Tan/orange medium sand
4 ft- 15 ft' Brown silty medium sand
5a.Well Location: 15 ft 20 ft Gray clayeyAne sand-,
Poco Shop #2 0-00-0000019204 ft. ft• r
Facility/Owner Name Facility ID#(if applicable) ft ft• r
940 West Broad Street, St. Pauls, NC zo�'
ft. ft.
Physical Address,City,and Zip 21.REMARKS
Robeson 0308-4661-7186
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)
34.810606 N 78.984445 W 01/10/2022
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 02C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 0No 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
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: 20 (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: 15.23 (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
Solid Stem Au 24aabove, also submit a copy of 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
constricted.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013