GW1-2021-02192_Well Construction - GW1_20210721

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
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1.Well Contractor Information:
4AWATERMONEs
Justin Radford
FROM TO DESCRtP.TION
Well Contractor Name 6 ft. 15 ft. i Gray.silty sand
3270 A �. ft ft. {
NC Well Contractor Certification Number �� 5•OiTERCFl51NG�tonulh casedells OR)I)[NERa. liable =
FROM TO DIAMETER THICKNESS MATERIAL
Geological Resources, Inc. ft. rt. ; "•
Company Name 1 116ANNER CASING'0RT,LMN.GT`eothermal°;closed=`too s, -
FROM TO DIAMETER THICKNESS MATERIAL
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2.Well Construction Permit 0 tt. 5 ft. 2" i" sch 40 PVC
List all applicable well permits(i.e.County,State, Variances'
1ct 'A spacl!,On rt ft.
3.Well Use(check well use): 9114SCREEN
Water Supply Well: FROM TO DIAMETER'' SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5 ft. 15 ft• 2 in' 0.010 sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) R. R. in:
❑Industrial/Commercial ❑Residential Water Supply(shared) 18GROUT :)
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 ft' 2 ft. Grout i pour
Non-Water Supply Well:
laMonitoring ❑Recovery 2 ft- 3 rt. bentoriite pour
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.eSAND/GRA�?EL PACK if,ap-plieable�
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 3 ft. 15 ft. Sand pour
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
;4120 DRILIANG1COGI`attacha`addihonal;stiee s if;necessa `, r,
❑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 ff 0.5 ff Asphalt
4.Date Well(s)Completed: Well ID#
05/27/2021 MW-27 0•5 ff 3 ft• Brown sandy silt, some clay
3 ft- 6 ft. Light gray to dark gray sandy silt
Sa.Well Location: 6 ft. 15 ft. Light gray cmf sand
Minute Man #24 0-00-0000018669
Facility/Owner Name Facility ID#(if applicable) ft. ft.
5102 Fayetteville Road, Lumberton, NC
ft. ft.
Physical Address,City,and Zip
21?�12EiifATiKS
Robeson 9393-7586-2100
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one]at/long is sufficient)
34.672056 N 79.007667 W / ,� 06/09/2021
Signature of Certified Well Contractor j Date
6.Is(are)the well(s): 2Permanent 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 FIND copy ofthis record has been provided to the well owner.
Ifthis is a repair,fill out known well construction infornmtion and explain the nature ofthe
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: 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: 15 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iit dierent(example-3@200'and 2@100') construction to the following:
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10.Static water level below top of casing: .59 (ft.) Division of Water Resources,Information Processing Unit,
Ifwaier 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
,l 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: 6" Rotary Auger 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 ServicelCenter,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-1 North Carolina Department of Environment and Natural Resources-Division of WateY Resources Revised August 2013