GW1-2023-01696_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:
Justin Radford ,�,14.WATER ZONES . ,�;F
FROM TO DESCRIPTION
Well Contractor Name 11 fr' 20 rr' I Tan sandy clay
3270 A
NC Well Contractor Certification Number _ -15.OUTER CASING for multi-cased wells OR LINER if a licable
:try j FROM TO DM IAETER THICKNESS MATERIAL
Geological Resources, Inc. b 2Q23 rt. ft. I, ' in.
Company Name r L't;;; 16.INNER CASING OR TUBING('eotberma►closed-loop)
^�.a=.-,..:;�.;���• � FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: =. .;�;: �' '. �i: ft. ft. 2" in' sch 40 PVC
List all applicable well permits(i.e.County,State, ce,Inject bte'n,°e .) 0 5
ft. rt. in.
3.Well Use-(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5 it. 20 rr• 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 -
FRONT TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 1" 1.5 rt• Grout Pour
Non-Water Supply Well:
1.5 rr• 3.5 tr• Bentonite Pour
OMonitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 3.5 fr• 20 rr• Sand Pour
❑Aquifer Test ❑Stormwater Drainage
it. rt.
❑Experimental Technology ❑Subsidence Control
`20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,'oil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 tt. 0.8 ft. I Concrete
12/20/2022 MW 2 0.8 ft, 11 ft. Tan fine sand
4.Date Well(s)Completed: Well ID#
11 rr• 20 rr• Tan sandy clay
5a.Well Location: ft. ft.
Speedway #8276 0-0000035793 ft. ft.
Facility/Owner Name Facility ID#(if applicable)
2131 Forest Hills West, Wilson, NC
Physical Address,City,and Zip
21.REMARKS
Wilson 3712-02-8401
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification: I
(if well field,one lat/long is sufficient) U
35.730421 N 77.952739 W, 12/21/2022
Signature of Certified Well Contractoi; Date
6.Is(are)the well(s): OPermanent or ❑Temporary
By signing this form,I hereby cert fy 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 ENO copy of this record has been provided to the well owner.
If this is a repair,fill out/drown well construction information and explain the nature of the
repair under#21 re»tarks section or on the back of this forn:. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.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,,
i
9.Total well depth below land surface: 20 (ft.) 24a. For All Wells: Submit this,form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3 a 200'and 2@a 100') construction to the following:
I
10.Static water level below top of casing:
.✓ (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 Iniection Wells ONLY: In addition to sending the form to the address in
Solid flight au 24aabove, also submit a copy I
f this form within 30 days of completion of well
12.Well construction method: Solid auger 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 m Method of test: 24c.For Water Supply&Iniection Wells,
(gp ) Also submit one copy of this font 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