GW1-2023-01530_Well Construction - GW1_20230218

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Justin Radford 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
3270 A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-casedltc wells)OR LINER(if a able)
FROM TO DIAMETER THICKNESS MATERIAL
Geological Resources, Inc. ft. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 2 ft. 2" in* sch 40 PVC
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) -
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER _ SLOT SIZE THICKNESS _ MATERIAL
❑Agricultural ❑MunicipaVPublic 2 ft 12 ft 2 i"' 0.010 sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 0.6 ft Grout Pour
Non-Water Supply Well:
EMonitoring ❑Recovery 0.6 fa 1 ft Bentonite Pour
Injection Well: ft. fa
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO - MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
1 ft 12 ft. Sand
❑Aquifer Test ❑Stormwater Drainage
-
ft. ft
❑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- 0.6 ft- Asphalt
01/26/2023 MW-18 0.6 ft. 5 ft. Tan backfill sand
4.Date Well(s)Completed: Well ID#
5 ft 12 It DPT;no recovery
5a.Well Location: ft. ft.
JP Davenport N/A ft - ft.
Facility/Owner Name Facility ID#(if applicable)
ft. -------
5961 Highway 264, Greenville, NC n ft. `,,... "1
it. �� .. ._..
Physical Address,City,and Zip 21.REMARKS r`(CL� 1 �LI 2
Pitt 5628-77-5114
County Parcel Identification No.(PIN) ._
Irst," 1 . :. ::,cca 7,2 Ur,*
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: '• u µ' •
(if well field,one lat./long is sufficient) 22.Certificatio)>^�
35.624490 N 77.225604 W �` t //Zii��cy,s
Signature of 'fled 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 ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 0No 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: 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 if different(example-3 4200'and 2@I00) construction to the following:
Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: n/a (ft.)
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 3.25 (in.) 24b.For Injection Wells ONLY: In addition to sending the form to the address in
Direct n u s h 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: f 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-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013