GW1--04350_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:
14.WATER ,- ` '''•
Justin Radford FROM TO DESCRIPTION
Well Contractor Name ft. ft.
3270 A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for 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 7 ft 2" tn• 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 ' ''''P.,Water Supply Well: FROM TO DIAMETER SLOT SIZE . THICKNESS MATERIAL
ft. ft. in.
❑Agricultural 0 Municipal/Public -
❑Geothermal(Heating/Cooling Supply) 0 Residential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO - MATERIAL EMPLACEMENT METHOD&AMOUNT
0 Irrigation ft. ft.
Non-Water Supply Well:
ft. ft.
©Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable) --
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
DExperimental 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 4 ft. Brown sandy silt
02/23/23 TMW-1 4 ft 10 ft DPT;no lithology
4.Date Well(s)Completed: Well m# ft. ft - - -'
5a.Well Location: ft. ft.
D.N. Food Mart 0-0000020533 ft ft. R v/ ---r$_ . ^�
P -- (, - r t1---- P n
Facility/Owner Name Facility ID#(if applicable) ft ft • • ........ k' ,s `.••,-a'r
605 North Hughes Blvd, Elizabeth City 27909 ft ft. JUL 0 '/ 2023
Physical Address,City,and Zip
21.'REMARKS ` '''
Pasquotank 891415731385 Ink-,n-r n 'e- r g I.1II.;i
County Parcel Identification No.(PIN) P°' {
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certificati • //
(if well field,one lat/long is sufficient)
36.310800 N 76.225581 W 0 V (V5
Signature of C ied Well Contra r Date
6.Is(are)the well(s): ❑Permanent or ©Temporary By signing t 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 ONo 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: 1 0 (ft.) 24a. For All Wells: Submit this form within 30 days.of completion of well
For multiple wells list all depths if d jerent(example-3(200'and 2@100) construction to the following: .
10.Static water level below top of casing: 3.05 (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: 225" (in.) 24b.For Injection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: D PT 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