GW1-2023-01694_Well Construction - GW1_20230214

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Matt Steele _ 1FR 4.WATER TONES DESCRIPTION
Well Contractor Name K j '. ;,j •- �^ ft. ft.
4548-A r�' �,a - r �• t7. i
t] �. 2023 15.OUTER CASING for multi-cased wells OR LINER it`a livable
NC Well Contractor Certification Number F tL, - FROM TO DIAMETER! THICENESS MATERIAL
Geological Resources, Inc. .n.�w .�:r s`•`J�`�'` ft. ft. i ,in
Company Name ,v�4 C}•3?✓� 16.INNER CASING OR TUBING eother al closed-loop)
FROM TO I DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft' 3 ft. 4 iO 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 ❑Municipal/Public 3 n 18 ft 4 1n 0.010 Sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft• in.
❑Industrial/Commereial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 1 ft. Grout • Pour
Non-Water Supply Well:
1 ft. 2 ft Bentoiiite Pour
❑Monitoring oRecovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a livable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 2 ft. 18 R' #2 Sand Pour
❑Aquifer Test ❑Stormwater Drainage
ft, ft. I
El Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardn soil/rock type size,eta
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 it. 0.5 ft. Brown silt
4.Date Well(s)Completed: 1 0/3/22 well lw RW-1 0'5 ft. 3 ft Red sandy clay
3 ft• 12 n Tan fine sandy clay
sa.well Location: 12 n 18 ft Tan fine sandy clay
New Dixie Mart #226 0-034646 n. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
4917 Raleigh Road Parkway West, Wilson 28364 ft. ft.
Physical Address,City,and Zip 21 REMARKS
Wilson 2793-73-2703 Soil becomes saturated around 12'.
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
35.7619960 N 77.9985590 W .yU�' 1/11/23
Signature of Certified Well Contractor' Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the we//(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 ©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 ofthe
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 I
submit one form. 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 multiple wells fist all depths ifili ferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: n/a (ft) Division of Water R isources,Information Processing Unit,
Ifwuter 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
6" Solid F l i Il t {1u a r$ 24a above, also submit a copy f this form within 30 days of completion of well
12.Well construction method: g 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 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 ofEnviror went and Natural Resources-Division of Water r Resources Revised August 2013