GW1-2021-02521_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:
Justin Radford FROM ER ZONES '. .
FROM TO DESCRIPTION
Well Contractor Name ft ft
3270 A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a gcable
FROM TO DIAMETER TffiCKNESS MATERIAL
Geological Resources, Inc. ft ft. in.
Company Name 16.INNER CASING OR TUBING eotherural closed-loop)`
WM-0601173 FROM TO DIAMETER THICKNESS MATERIAL.
2.Well Construction Permit#: 0 fL 5 ft- 2 in. soh 40 PVC
List all applicable well permits(i.e.County,State,Variance,Injection,etc)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SUE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5 ft 15 ft. 2 in. 0.010 sch 40 PVC
❑Geothermal (Heating/Cooling Supply) ❑Residential Water SuPP1Y(single) ft. ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
[]Irrigation 0 ft 3 ft- Grout
Non-Water Supply Well:
ft, ft.
oMonitoring ❑Recovery
Injection Well: fL It.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a lkable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 3 It. 4 ft Bentonite
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 4 ft 15 ft. 'Sand
`20.DRILLING LOG"attach additional sheets'if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain s etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 4
21 Remarks 0 ft. 1 fL Gravel
4.Date Well(s)Completed: Well ID#
04/14/2021 GMW-1 1 ft. 4 ft. Orange clayey sand
4 fL 15 ft. DPT;no recovery
5a.Well Location: ft. ft.
T Mart Amoco 0-000017633 ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft.
511 Spring Branch Road, Dunn, NC tt. ft. JUN
Physical Address,City,and Zip 21.REMARKS
Harnett 215-270-252 Information Processing Unit
County Parcel Identification No.(PIN) uvvK section
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient) /)i ��
35.293644 N 78.604777 W `v,/°� Af- 05/04/2021
Signature of Certified Well Contractor Date
6.Is(are)the well(s): 2Permanent or ❑Temporary By signing this form,I hereby certtfy 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 EINo 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
S.Number of wells constructed: 1 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 ifdifferent(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: 6.86 (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:.3.25 (in.) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
DPT rods 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 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