GW1-2021-02154_Well Construction - GW1_20210721

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Justin Radford 14•'WATERZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
3270 A ft. ft.
NC Well Contractor Certification Number 152OUTER CASING for multi-cased wells OR LINER` ii`livable
FROM TO DIAMETER I TRICKINESS I MATERIAL
Geological Resources, Inc. ft. ft. i in.
Company Name 16.INNER CASING OR TUBING "e6therbW'cIWd-1od6
2.Well Construction Permit#. -
WM0701242 FROM TO DIAMETER THICKNESS MATERIAL`
+4 ft. 2 ft. 2 in• sch 40 PVC
List all applicable well permits(i.e.County,State, Variance,Injection,etc.)
ft. it.
3.Well Use(check well use): 0.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SUE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 2 it 12 ft 2 in' 0.010 sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft & 1n.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.i_GROUT
FROM TO MATERIAL y EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0
Non-Water Supply Well: ft 0.5 ft Grout Pour
ft. ft
OMonitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19..SAND%GRAVEL PACK FROM TO MATERIAL EMPLACEMENT METHOD if a d"Rcabte
❑Aquifer Storage and Recovery . ❑Salinity Barrier 0.5 ft. 1 ft Bentonite Pour
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 1 It. 12 ft Sand Pour
20..DRILLING LOG attach additio"d"al sheeti if necei"sa 6,_, ,2-_-
0 Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardnea roil/rock typt,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 2 ft. Brown fine sand
4.Date Well(s)Completed: 04/27/2021 Well ID#MW-42R 2 ft 6 ft. Gray clay
6 & 12 ft. Gray fine sand
5a.Well Location: ft ft
Perry's Grocery/Harrell's Gulf 00-0-00000302e6&004)-0000022919
ft ft
Facility/Owner Name Facility ID#(if applicable)
696 NC Highway 42, Trap, NC ft. ft.
Physical Address,City,and Zip 21.:REMARKS 77
Bertie 6920-72-5218
County Parcel Identification No.(PIN) Information Processing
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certif lion:
(if well field,one lat/long is sufficient)
36.206222 N 76.869722 W 05/28/21
SignoAWv of Certified Well ontractor Date
6.Is(are)the well(s): 2Permanent or ❑Temporary By signing this form,I hereby certify that the wells)was(were)constructed in accordance
with I SA 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 IDNo 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 pageto 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: 12 (ft.) 24a. For All Wells: Submit this!form within 30 days of completion of well
For multiple wells list all depths ifdi(jerent(example-3(200'and 2@1001 construction to the following:
10.Static water level below top of casing:4.91 (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: 3.5 (in.) 24b.For Infection Wells ONLY: 11n addition to sending the form to the address in
Hand Au er 24aabove, also submit a copy of this form within 30 days of completion of well
12.Well construction method: g 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 i 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