GW1-2021-02410_Well Construction - GW1_20210601

WELL CONSTRUCTION RECORD
For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: ED�'
Justin Radford �ECE 14 WATER&zoNEs
FROM TO DESCRIPTION
Well Contractor Name 3.5 rt' 12 rt• unknown
3270 SUN X 2021 rt. ft.
, f
NC Well Contractor Certification Number information
Processing Unit 15:*4OUTER:GASING!form"lu h cased wells"'?%UINER if a licable
WR Section FROM TO DIAMETER THICKNESS MATERIAL
Geological Resources, Inc. D ft. ft. in.
Company Name 16 INNER CASING,ORgT[JBINGu oihermal closed=loo� •,
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: NSA 0 ft' 2 tt. 2 i" SCh 40 PVC
List all applicahle well permits(i.e.County,State, Variance,Injection,etc)
ft. ft. in.
3.Well Use(check well use): 2
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 2 ft. 12 rt• 2 in• 0.010 SCh 40 PVC
f. f. i"•
❑Geothermal(Heating/Cooling Supply) ❑Residential Water SuPPIY(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18•GROUT, � -
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑bTi ation 0 r" 0.5 rt- Cement pour
Non-Water Supply Well:
OMonitoring ❑Recovery
0.5 rt. 1 rt. bentoriite pour
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 1%.SANWGRMVEIsPACK"d
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 1 ft- 12 rt• Sand pour
❑Aquifer Test ❑Stormwater Drainage ft. fa
❑Experimental Technology ❑Subsidence Control
„20: 'RILL7NG)LOGrafta-c-cHVdditio`nal.sheet§'.if.necess`a"' em s A,_
❑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 e• 12 rt• DPT; no recovery
4.Date Well 04/13/21s)Completed: Well ID#GMW-2
ft. ft.
5a.Well Location:
Exprezit 2834 00-0000034564 ft, ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
1305 West Blvd, Williamston, NC tt.
Physical Address,City,and Zip 2LAENIARKS.; :-- _,
Craven 7-009
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)
35.081790 N 77.030344 W 04/23/21
Signature of Certified Well Contractor 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 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 hack ofthis 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: 12 (ft.) 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: 3.81 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: 3.5 (in.) 24b. For Infection Wells ONLY; In addition to sending the form to the address in
3.5 DPT 24aabove, also submit a 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 i enter,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