GW1-2022-00311_Well Construction - GW1_20221222

WELL CONSTRUCTION RECORD For Internal Use ONLY: j
This form can be used for single or multiple wells
1.Well Contractor Information:
Matt Steele �Fx MATER TO NEST_ DESCRIPTION
Well Contractor Name ft. ft.
4548 A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINERlicable
FROM TO HI DIAMETER TCKNESS MATERIAL
Geological Resources, Inc. ft fr I in.
Company Name 16.INNER CASING`OR TUBING(geothermal closed-loop)
WM-0601193 FROM I TO HI DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 fL 2 ft. 2" �' sch 40 PVC
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft. I ft , in.
3.Well Use(check well use): 17.SCREEN s_
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 2 ft. 12 ft. 2 "D 0.010 sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
101rrigation 0 1 0.5 fL Grout ' pour
Non-Water Supply Well:
0.5 ft. 1 ft. Bentonite pour
©Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 1 fL 12 ft. Sand
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soilfrock type n size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 0.4 ft. Asphalt
4.Date Well(s)Completed: Well ID#
10/26/2022 MW-17 0.4 ft. 3 ft. Tan fine sand
3 ft. 9 ft. Black fine sand
5a.Well Location: 9 ft. .12 fL " Gray fine sand
JECO (J&J Texaco) 00-0-0000019342 ft. fL
Facility/Owner Name Facility ID#(if applicable) ft. ft
610 Union Chapel Road, Pembroke, NC -
ft. ft. .t ia.. .,.r -a V Y....,LJ"
Physical Address,City,and Zip 21.REMARKS .`,
Robeson 9344-4037-4400
County Parcel Identification No.(PIN)
_• Iftiir:3i:a:E��1 1:0
56.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: D sNQi3oc-
(ifwell field,one lat/long is sufficient) 22 Ct.dfic .
34.686412 N 79.185758 W 11/02/2022
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ❑Permanent or 2Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15.4 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 ©No 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
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: 12 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list,all depths ifel fferent(example-3@200'and 2@100) construction to the following:
h
10.Static water level below top of casing: n/a (ft,) Division of Water Resourees,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
1
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells ONLY:I In addition to sending the form to the address in
Solid flight auger 24aabove, also submit a copy of�this form within 30 days of completion of well
12.Well construction method: Solid construction to the following:
(Le.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 Environment and Natural Resources-Division of Water Resources Revised August 2013