GW1-2023-01564_Well Construction - GW1_20230209

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WELL CONSTRUCTION RECORD For Internal Use ONLY: j
This form can be used for single or multiple wells
1.Well Contractor Information:
Matt Steele FROM TO ZONES DESCRIPTION
Well Contractor Name ^� ^�7,- -1 a -. ft. fL f
4548 A � ;t. s ' � It. ft I i
NC Well Contractor Certification Number FEB
,S (1 15.OUTER`- G CASIN (for cased wells OR LINER if a licable
I D V l.� FROM TO DIAMETER THICENESS MATERIAL
Geological Resources, Inc. ft. ft. !in.
Company Name i `"k ° `'' 16.INNER CASING OR TUBING(geothermal closed-loop)
WM060123 ' °'o; o'`� FROM TO DIAMETER TMCKNESS MATERIAL`
2.Well Construction Permit#: 0 It' 18 ft 2 In- sch 40 1 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 ❑Municipal/Public 18 ft. 28 It. 2 in. 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
❑Irri ation 0 fL 14 ft- Grout Pour
Non-Water Supply Well:
14 ft 16 ft- Bentonite Pour
EMonitoring ❑Recovery
Injection Well: fL ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
16 ft. 28 ft. Sand Pour
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if uecessa
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION color,hardnes soNrock type,grain size,eta
❑Geothermal(Heating/Cooling Return) El Other(explain under#21 Remarks) 0 ft. 0.5 ft Concrete
4.Date Well(s)Completed: y29/2022Well ID#MW-1 0.5 ft- 15 ft. Tan sand
15 IL 17 ft Tan sand with gray clay
sa.Well Location: 17 ft 22 rt Gray clay with sand
Safeway 4 0-00-0000017950 22 ft. 24 ft. Gray clay
Facility/Owner Name Facility ID#(if applicable)
318 Harris Ave, Raeford, NC 24 fLft- 28 f� Coarse tan sand
Physical Address,City,and Zip 21 REMARKS
Hoke 6943-4090-1045
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification.
(if well field,one lat/long is sufficient)
34.977927 N 79.230766 W 01/23/23
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ❑O Permanent or ❑Temporary 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 KNo 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: 28 (ft.) 24a. For All Wells: Submit thi form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3 @2 00'and 2Q100 construction to the following:
10.Static water level below top of casing: 18.51 (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 Stem Au er 24aabove, also submit a copy of this form within 30 days of completion of well
12.Well construction method: 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 276994636
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.
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Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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