GW1-2021-02168_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.AVATER,ZONES =T ,
FROM TO DESCRIPTION
Well Contractor Name yes 10 ft. 18 ft. Tan fine sand
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3270 A ft. ft.
^O^� `I5.'OUTER;CrASIN_Gafo'rm Ih eased`wells"OR INER fa licatile
NC Well Contractor Certification Number L L J,1 TER THICKNESS MATERIAL
Geological Resources, Inc. U knit FROM fL TO fL DIAME in.
Company Name a, 3�0 I r On &JNNER(CA5ING OR�T_UBING1 eoih"li ltc'losed"L"oo
1('tiJC�" R sgo.,'t1 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 8 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): 'j 17.4SGREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 8 ft. 18 tt• 2 in. 0.010 sCh 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 6g0GROUT '
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 4 ft- Grout pour
Non-Water Supply Well:
OMonitoring ❑Recovery 4 rt. g ft. Bentonite pour
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation x 19"`SANDIGRAVE Pt1(CKa il' 'l0able
FROM TO- MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery []Salinity Barrier 6 ft. 18 ft' Sand pouf
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
«;�.20tDRI1sL`7NGlLOG at'tiicti�adiliti5nal sheefsgif,necessa ":'� ��
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 0.5 ft. Asphalt
06/16/2021 MW-2, 3, 4 0.5 ft. 3 ft' Light brown sand
4.Date Well(s)Completed: Well ID#
3 ft. 4 rt. Gravel
5a.Well Location: 4 ft. 5 ft. Brown fine sand
RL Village 0-000036169 5 ft. 10 ft. Dark brown/red sand
Facility/Owner Name Facility lD#(ifapplicable) 10 tt' 18 tt Tan fine sand
5194 South NC 41 Highway, Wallace, NC
Physical Address,City,and Zip „21 AREMA'RKS #
Duplin 3316-0258-6405
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)
34.757854 N 77.948573 W 06/18/2021
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By,signing this form,1 hereby certify'that the well(s)was(were)constructed in accordance
with 1 5A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes Or BNO 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: 3 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: 1 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiereni(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: ~1 3 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 6 (in.) 24b. For Infection Wells ONLY,: In addition to sending the form to the address in
II 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: 6" Flight Auger construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
f
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
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013