GW1-2022-08269_Well Construction - GW1_20220826

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor information:
Frank Beecher 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
3225-A 3.81 ft N/A ft Shallow Aquifer
ft. it
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a licable
AECOM Technical Services of North Carolina, Inc. FROM TO DIAMETER RffiClavESS MATERIAL,
ft ft is
Company Name
16.INNER CASING OR TUBING(geothermal closed-loo
N/A FROM TO DIAMETER THICENESs MATERw.
2.Well Construction Permit#:
List all applicable well constructionpermits(i.e.UIG County,State,Variance,eta) 0.0 ft• 2.0 ft 2.0 in- .040 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
PP Y FROM TO DIAMETER SLOT SIZE TMCKNESS MATERIAL
Agricultural QMunicipal/Public 2.0 fa 7.0 ft 2.0 in- .010 .040 PVC
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
Industrial/Commercial 0Residential Water Supply(shared) i&GROUT
Irrigation FROM I TO MATERIAL. EMPLACEMENT MET11OD&AMOUNT
Non-Water Supply Well: N/A ft ft
x Monitoring ORecovery ft. ft
Injection Well: ft ft
Aquifer Recharge QGroundwater Remediation
19.SAND/GRAVEL PACK if a Gcahle
Aquifer Storage and Recovery [Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage 7.0 & 1.5 & #2 Drillers sand By Hand
Experimental Technology E]Subsidence Control ft fL
Geothermal(Closed Loop) nTraccr 20.DRILLING LOG attach additional sheets if necessary)
Geothermal FROM TO DESCRIPTION color,hardaw soiVmek sve et
(Heating/Cooling Return) Other(explain under#21 Remarks)
0.0 & 1.0 st dry grey brown sand
4.Date Well(s)Completed:8.11.22 Well ID#T-1 1.0 It. 2.0 f' dry greyblack sand
5a.Well Location: 2.0 n' 3.0 f" dry black fine silty sand
7-Eleven/Speedway 47027-82 0-034515 3.0 ft 4.0 ft moist black fine silty sand
Facility/Owner Name Facility ID#(ifapplicable) 4.0 fr 5.0 ft wet black silt
10816 NC Hwy 55 East, Grantsboro, NC 28529-9439 5.0 & 6.0 ft wet brown/tan silty sand
Physical Address,City,and Zip 6.0 ft 7.0 fc wet brown/tan sandy silt
Pamlico 654153108000 21.RENIARKS
County Parcel identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one ladlong is sufficient) 22.Certif1 anon:
35.140212 N -76.841400 W 08.12.22
Signature ofCertified Well Contractor Date
6.Is(are)the well(s)�IPermanent or �x�Temporary
By signing this form,I hereby certfy that the well(i)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or [H)No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and char a
1f this is a repair,fill out kntnvn well construction information and esplain the nature of the copy of this record has been provided to the well owner.
repair under 1121 remarks section or on the hack 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 details. You may also attach additional pages necessary'' '•r F ,
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells ,t--
r
drilled: SUBMITTAL INSTRUCTIONS n II''r(�
9.Total well depth below land surface: 7.0 (ft) 249. For All Wells: Submit this form within 30 days of AMget2n Gf 222
For multiple wells list all depths if dijjerew(example-3@a 200 and 2Q100') construction to the following:
3.81 nfo;wtiEs"uCn ;J;cc:,ra t? UnA
10.Static water level below top of casing: (ft) Division of Water Resources,Information processing!�pj BOC_
Ifwater level is above casing,use"1" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diamcter:2.75 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Hand Auger 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) Method of test: 24c.For Water Supply&injection 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: Amount: completion of well construction to the county health department of the county
where constructed.
Form GWA North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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