WQ0003626_Well Construction_20140915

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Grady Dobson
Well Contractor Name
4076E
NC Well Contractor Certification Number
Environmental Hydrogeological Consultants,Inc
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑Irrigation
❑Municipal/Public
❑Residential Water Supply (single)
DResidential Water Supply (shared)
Non -Water Supply V'ell:
EIMonitoring ❑Recovery
Injection Well:
DAquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
4. Date Well(a) Completed: 9/15/14
5a. Well Location:
Campbell Soup Supply Co.
Facility/Owner Name
Well ID# MW-7A
Facility ID# (if applicable)
1313 Modest Road,Maxton,NC 28364
Physical Address, City, and Zip
Robeson
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(dwell field, one lat/long is sufficient)
34°48'12"" N 79°18'14"
6. Is (are) the well(s): I2Permanent or ❑Temporary
W
7. Is this a repair to an existing well: ❑Yes or ElNo
If this is a repair, fill out known well construction information and explain the nature of the
repair under a21 remarks section or on the back of this form.
8. Number of wells constructed: one
For multiple injection or non -water supply wells ONLY with the sane construction, you can
submit one form.
9. Total well depth below land surface: 25 (ft.)
For multiple wells list all depths if di)ferent (example- 3@200' and 2@I00')
10. Static water level below top of casing: 11 (ft,)
If water level is above casing, use "+ "
11. Borehole diameter: 2 (in.)
12. Well construction method: auger
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
1313. Disinfection type: Amount:
For Internal I'se ONLY:
14. WATER ZONES
FROM
TO
DESCRIPTION
ft
ft.
ft.
ft
15. OUTER CASING (for multi -eased wells OR LINER (if ap linable)
FROM
TO
DIAMETER
THICKNESS MATERIAL
ft.
ft.
in.
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
ft
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
5 ft
25 ft
2 in.
0.01
ft
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
2 ft
4 ft
Bentonite
0 rt.
2 ft
Concrete
ft
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
4 ft
25 ft
ft
ft.
20. DRILLING
LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soil/rock hpe, grain size, etc.)
0 ft
1 ft.
organic material
1 ft.
6 ft
yellow fine sand
6 ft.
15 ft.
orange fine sand
15 ft
18 ft.
red fine sand
18 ft
21 ft•
white coarse sand
21 ft
25 ft•
white coarsepIr)cI wits Aea_gravel
ft
ft.
►... i ...:
21. REMARKS
SEA 2014
22. Certifi. lion:
Si e of Certified W 1 Co) tractor
INFORMATION RROCESS;NG u ) I
By signing this form, 1 hereby certf that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 1 SA NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details: •
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Quality, Information Processin
1617 Mail Service Center, Raleigh, NC 27699-1 1�
NR-FRO _
24b. For Iniection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of complgEf a,e0 2014
construction to the following:
Division of Water Quality, Underground Injection Control Prog a J
1636 Mail Service Center, Raleigh, NC 27699-1636 /
24c. For Water SuDDIV & Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Form GW-1
North Carolina Department of Envoonment and Natural Resources - Division of Water Quality Revised Jan. 2013

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