GW1-2023-01573_Well Construction - GW1_20230209

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
i
1.Well Contractor Information:
Justin Radford 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft.
NC Well Contractor Certification Number
15.OUTER CASING for mulfi-cased wells OR LINER.if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Geological Resources, Inc. FtB 4 9 2023 ft. ft. I ! I in.
Company Name 16.INNER CASING OR TUBING eother al closed-loop)
lni+vin%c3 ion f r:^.;?iti, :nu FROM TO I DIAMETER THICKNESS MATERIAL
uJ+� in.
2.Well Construction Permit#: 0 ft. 3 ft. 2n sch 40 PVC
List all applicable well pennits(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 3 ft, 18 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) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 1 ft- Grout Pour
Non-Water Supply Well: 1 ft. 2 ft. Bentonite Pour
Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ifa licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
2 IL 18 ft. Sand Pour
❑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,soiUrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 0.2 ft. Asphalt
4.Date Well(s)Completed: 01/10/2023Well ID#MW-1 0.2 ft' 6 ft. Red sandy clay w/river rock
6 ft 15 ft. Tan clayey sand
5a.Well Location:
New Dixie Mart#230 00-0-0000029770 15 ft. 18 ft. Tan clayey sand
18 ft• 20 ft. Light tan clayey sand
Facility/Owner Name Facility ID#(if applicable)
10654 NC Highway 903, Halifax, NC ft. ft.
Physical Address,City,and Zip 2L REMARKS
Halifax 3995-03-13-0521
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)
36.362675 N 77.671858 W 01/11/2023
Signature of Certified Well Contractor: Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this farm,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 retard 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 saute construction,you can
submit one fornn. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 18 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For nmdtiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing:4.96 (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 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,
hn C NC 27699-1636
1636 Mail Service eter,Raleigh,FOR WATER SUPPLY WELLS ONLY: I g
m 13a.Yield
(gp ) Methodof 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.
Forth GW-1 North Carolina Department of Environment and Natural Resources-Division of Water R e'sources Revised August 2013