GW1-2021-02157_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 R 14:WATERZONE3' ` fa n y y f ,+
FROM TO DESCRIPTION
Well Contractor Name 11'
3270 A J V 1 202 ft ft.
ft.
NC Well Contractor Certification Number
415.OUTER CASING'fo multi=cased wells'OR`LINER ift" Iicable Infor=bOn Processing
DWR Section FROM I TO I DIAMETER TMCiQNESS MATERIAL
Geological Resources, Inc. fL ft
Company Name 46. CASINGiORTUWNW eotheemal closed=loo" ,'„
WM-0701245 FROM TO DIAMETER THICKNESS MATERIAL,
2.Well Construction Permit#: 0 ft. 2 ft 2 in. sch 40 PVC
List all applicable well permits#.e.County,State, Variance,Injection,etc.)
it. ft. in.
3.Well Use(check well use): 17.SCREENS
Water Supply Well: FROM TO DIAMETER I SLAT SIZE THICLQNESS I MATERIAL
❑Agricultural ❑Municipal/Public 2 ft 12 % 2 ini 0.010 Sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fL ft. in:
❑Industrial/Commercial ❑Residential Water Supply(shared) 8.GROUT " si ,r -: y
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
olrriitation 0 fL 0.5 fL Grout
Non-Water Supply Well: ft. ft.
OMonitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 419.SAND/GRAVEVPACK ;s Ileable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 0.5 ft. 1 ft. Be'ntonite
❑Aquifer Test ❑Stormwater Drainage
1 ft. 12 ft. Sand
❑Experimental Technology ❑Subsidence Control 4U0 DRILLING;I OG attach sildltlonal;aheets if neceiia" '.,1�^ # ,x
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hrardn soWrock tic
❑Geothermal eating/Cooling Return ❑Other(explain under#21 Remarks) 0 ft 2 ft' Brown fine sand
04/26/2021 MW-31 2 ft. 8 ft. Orange to gray clay
4.Date Well(s)Completed: Well ID#
8 it- 12 ft. Gray fine sand
5a.Well Location: & %
Perrytown Service Center 00-0-0000022792 it. %
Facility/Owner Name Facility ID#(if applicable) ft ft•
526 Sand Hill Road, Colerain, NC ft ft.
Physical Address,City,and Zip Z1.REMARKS ,
,z
Bertie 6847-86-7446 Wet at 8 ft.
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)
36.138194 N 76.803389 w - �` 05/28/21
SignaturC of Certified Well Co tractor ! 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.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo 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 eonstruedon,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 12 (ft.) 24a. For Ail Wells: Submit this,form within 30 days of completion of well
For multiple wells list all depths if dtjjerent(example-3@200'and 2@1001 construction to the following:
j
10.Static water level below top of casing: N/A A'V/A (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 3.5 (in.) 24b.For Infection Wells ONLY: !In addition to sending the form to the address in
Hand Au 24aabove, also submit a copy of this form within 30 days of completion of well
er
12.Well construction method: 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
24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test: Also submit one copy of this form within 130 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
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