GW1-2021-02185_Well Construction - GW1_20210721

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
i
1.Well Contractor Information:
Justin Radford ' RIONVATER;ZON_ES t t r '
'� FROM TO DESCRIPTION
Well Contractor Name ft ft
3270 A � \\` ,Z 1 1011 �t ft ft
NC Well Contractor Certification Number �r9vn l5'OUTER CASING„for mulh=ca``sed»ells RV IN licabl'e g
tJS FROM TO DIAMETER THICKNESS MATERIAL
Geological Resources, Inc. ton�'�oeIDP rt. ft. in.
Company Name J%0 x 06 INNER C ISING(OR57',J.BING?(eothermairelosed'-1oi <
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): M74SCREEN z�
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5 tt 20 ft' 2 i" 0.010 sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) tt. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18XIG
ROU9
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 3 ft. Grout; pour
Non-Water Supply Well:
RMonitoring ❑Recovery 3 tt. 4 ft. Bentonite pour
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation "-19 SANDIGRAq,EI NGKi if a 7icable �, x
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 4 ft. 20 ft. :band pour
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control 20DRILL7NGtL°OGfattach ad"diHoial sheets if,necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,gmin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 2 Light brown sand
06/15/21 MW-5, 6, 7, 8 2 ft. 3 ft. Brown/red clay
4.Date Well(s)Completed: Well ID#
3 ft. 5 ft. Brown/red coarse sand
5a.Well Location: 5 ft. 15 tt Red medium sand
EP Mart#16 0-0000036065
15 ft• 20 rt• Tan medium sand
Facility/Owner Name Facility ID#(if applicable)
1800 Benvenue Road, Rocky Mount, NC
Physical Address,City,and Zip f,21RE111ARKS° sa
Nash 047361
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)
35.984165 N W 77.812668 06/18/2021
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.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or END 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:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed:4 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 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@I00') construction to the following:
10.Static water level below top of casing: — 14 (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 Infection Wells ONLY: In addition to sendingthe form to the address in
It 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: 6 solid flight auger construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) i
Division of Water Resources,Vnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service'Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply&Injection Wells:
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-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013