GW1-2022-10493_Well Construction - GW1_20221118

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Justin Radford 1 .WATERZONES
f\ U FROM TO DESCRII'TION
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 licable
FROM TO DIAMETER THICKNESS I MATERIAL
Geological Resources, Inc. ft. ft. I in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 3 ft. 2" in. sch 40 PVC
List all applicable well permits(i.e.County,State,variance,It jection,etc)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 3 ft. 8 ft. 2 in. 0.010 sch 40 PVC
❑Geothermal(Heating/Cooling Supply) El Residential Water SuPPIY(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO XATERIAL EDIPLACENIENT bIETHOD&AMOUNT
❑hrigation 0 ft. 0.5 ft. Grout Pour
Non-Water Supply Well:
0.5 fr. 1 ft. Bentonite Pour
©Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge El Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACENIENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 1 ft. 8 ft. Sand Pour
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
El Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑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 ft. 8 ft. Tan medium sand
4.Date Well 09/19/2022 s)Completed: Well ID#MW-4R ft. ft.
5a.Well Location: ft. ft. " tir, °ti•m;^V i, �
Handy Mart#18 00-0-0000017038 ft. ft. NfiV 1
Facility/Owner Name Facility ID#(if applicable)
6890 US Highway 64, Robersonville, NC
Physical Address,City,and Zip
'21.REMARKS
Martin 0702054
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one hit/long is sufficient)
35.826771 N 77.244339 W 09/23/2022
Signature of Certified Well Contractor Date
6.Is(are)the well(s): RPermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constnicted 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 FlNo 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 921 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
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or nor-water supply wells ONLY with the saute construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 8 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if tli ferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: n/a (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b. For Infection Wells ONLY: In addition to sending the form to the address in
Solid fli ht au er 24aabove, also submit a copy of this form within 30 days of completion of well
12.Well construction method: g g 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-I North Carolina Department of Enviromnent and Natural Resources-Division of Water Resources Revised August 2013