GW1-2023-01744_Well Construction - GW1_20230213

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Justin Radford F4.WATER ZONES
FROM TO DESCRIPTTON
Well Contractor Name ft. ft.
3270 A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased welb OR LINER a licabb
FROM TO DIAMETER THICKNESS MATERIAL
Geological Resources, Inc. ft I ft in.
Company Name 16.INNER CASING OR TUBING othermal dosed-lee
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)
It. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic 2 ft. 12 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 TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hTi ation 0 ft• 0.6 ft. Grout Pour
Non-Water Supply Well:
0.6 ft- 1 ft- Bentonite Pour
EMonitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
1 tt• 12 tt• Sand
❑Aquifer Test ❑Stormwater Drainage
ft. fL
❑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 •6 ft. Asphalt
4.Date Well(s)Completed: Well ID#
01/26/2023 MW-18 0.6 it. 5 ft. Tan backfill sand
5 rL 12 ft DPT;no recovery
5a.Well Location: ft. ft
JP Davenport N/A ft. ft.
Facility/Owner Name Facility ID#(if applicable)
5961 Highway 264, Greenville, NC ft. ft
Physical Address,City,and Zip 21 REMARKS
Pitt 5628-77-5114 L 1
County Parcel Identification No.(PIN) " Llri'
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certiticatio .� u
(if well field,one lat/long is sufficient)
35.624490 N 77.225604 W
Signature ofC ified 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 15A NCAC 01C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or F1No copy ofthis 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 ifdierent(example-3 aW00'and 2@100) construction to the following:
10.Static water level below top of casing: n/a (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: 3.25 (in.) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
Direct nn u s h 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: r 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