GW1-2021-02231_Well Construction - GW1_20210722

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Brian James Bellis 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
NCWC 3510-A 3.1 ft" >12 fr' Water table
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased lweils OR LINER if a livable
WithersRavenel, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft- 2 tt. 0.75 SCh. 40 PVC
NA 16.INNER CASING OR TUBING teeothermal closed-loop
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well con.slruclion pernuls(i.e.WC,Couniv,Stale, I'artatce,etc.) 0 ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public 2 rt. 12 ft 0.75 in.` '10 SCh. 40 PVC
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.'
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
_ Irl'1 ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 1.0 ft Concrete our
x'Monitoring Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge 13Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
_ Aquifer Storage and Recovery OSalmity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test C]Stormwater Drainage 1.5 ft- 12.0 ft- Sand UST excavation backfill
Experimental Technology OSubsidence Control ft. fr.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets ifnecessa
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/mck type,gmin size,etc.
0 rt• 1.0 ft- Crushed stone backfill
4.Date Well(s)Completed:6/23/21 Well ID#MW-1 1.0 ft- 12.0 ft- Clean`sand backfill
5a.Well Location: ft. ft.
Quick Stop Food Mart 0-0-15721 ft. ft.
ft.
Facility/Owner Name Facility iD#(if applicable) ft.
312 E. Battleboro Ave, Battleboro 27809 ft. ft.
Physical Address,City,and Zip ft. ft. IUL
Edgecombe 3873-17-2680 21.REMARKS J t
County Parcel Identification No.(PIN)
1y1`
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one[at/long is sufficient) �Certifi,.tion:36.04423 N -77.74509 W �� -• 7-13-21
6.is(are)the well(s)ox Permanent or Temporary Signature ofCerti d W Contractor Date
By signing this form 1 hereby certify that the ire//(s)was(were)consirticied in accordance
7.Is this a repair to an existing well: Oyes or gNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and Ili&a-
ff this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under s21 remarks.section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 12.1 1 ft.
p ( ) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3 f( 200`and 2 a 100') construction to the following:
10.Static water level below to of casing:3.1 1 ft.
P g� ( ) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:2.0 (in.) 24b. For Infection Wells: In addition'to sending the form to the address in 24a
Geoprobe above,also submit one copy of this'form within 30 days of completion of well
12.Well construction method: 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
13a.Yield(gpm) NA Method of test: NA 24c. For Water Supply& Infection Wells: in addition to sending the form to
the address(es) above, also submit)one copy of this form within 30 days of
13b.Disinfection type: NA Amount: NA completion of well construction to the county health department of the county
where constructed.
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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