GW1-2022-10498_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:
14.WATERZONES
Matt Steele FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
4548 A ft. fL
NC Well Contractor Certification Number 15.OUTER CASING for roultl-eased:wells OR LINER' a" livable
FROM TO DIAMETER THICKNESS MATERIAL
Geological Resources, Inc. ft. ft. in. I
Company Name 16.INNER CASING OR'TUBING(geothermal closed-loop)
WM-0501508 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft' 15 ft. 2 HL sch 40 PVC
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) % ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 15 ft. 30 ft. 2 in. 0.010 sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. . ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 'IS'GROUT,
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hri ation 0 ft. 10 ft. Grout Pour
Non-Water Supply Well:
10 ft 13 ft- Bentonite Pour
©Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK Ta livable
FROM TO MATERIAL EMPLACEMENT METHOD
[]Aquifer Storage and Recovery []Salinity Barrier 13 ft. 30 ft. Sand
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets K necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION color,hardnesN soiVrock type s etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 fL 6 ft. Brown silt
4.Date Wells)Completed:
10/04/22Well ID#GMW-3 6 ` 18 ft. Red silt
18 ft. 24 ft. Red silt
5a.Well Location:
24 ft• 30 ft. Red silt
Former J.M. Daniel Grocery 00-0-0000000233 ft. ft. .
Facility/Owner Name Facility ID#(if applicable) ft. ft '-
2226 NC Highway 4, Littleton, NC ft. ft NUV1 8 2022
Physical Address,City,and Zip 21 REMARKS
Halifax 0700853 _ tfrl County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22:(`er�tati
(if well field,one lat/long is sufficient) t
36.392259 N 77.9000065 W; / 11/08/2022
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent 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 E]No copy of this record has been provided to tie 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
8.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: 30 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(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,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
Solid fli tit 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,directpush,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.
Farm GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013