GW1--04339_Well Construction - GW1_20230707

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
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
3270 A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING Tor multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER THICKNESS MATERIAL
Geological Resources, Inc. ft. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
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.) •
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE . THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 2 ft• 10 ft. 2 tD' 0.010 sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) it it in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO , MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 0.5 ft. Cement Pour
Non-Water Supply Well:
©Monitoring ❑Recovery 0.5 ft 1 ft* Bentonite Pour
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL. EMPLACEMENT METHOD
❑Aquifer Storage and Recovery El Salinity Barrier
1 ft' 10 ft. Sand
❑Aquifer Test ❑Stonnwater Drainage •
ft. ft.
❑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) DOther(explain under#21 Remarks) 0 ft. 6 ft. Orange fine sand
04/13/2023 MW-22 6 ft• 10 ft' Moist gray sandy clay
4.Date Well(s)Completed: Well ID#
10 ft. 11 ft. Brown medium sand
5a.Well Location: ft. ft. P i`  3. ".r 'r .y "
• Main Street Station 0-000006311 -±. 'i "a �`" �
ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. J IJ I © 2023
606 East Main Street, Plymouth, NC ft. - ft.
,- *., l
Physical Address,City,and Zip 111 : �r• =`'t^'1 J r :y lynx
21.REMARKS `i5 ^Z[Z ,
Washington 6767-98-0884
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one!at/long is sufficient)
35.868778 N 76.742306 �, `(/Y/ 3
Signatur of Certified ell Con or Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,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 ENo 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: 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
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 10 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'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: 6 (in.) 24b.For Infection Wells ONLY: In addition to sending the form to the address in
Solid flight auger 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: 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
24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test: 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