GW1--00511_Well Construction - GW1_20240118

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Sam Bowers 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
3220-A ft. ft. 1
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. 0 ft. 20 ft. 2 I ! in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop).
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft, 30 ft. 2 1'. 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 30 ft. 35 ft. 2 in. 0.010 Sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
1❑Industrial/Commercial ❑Residential Water Supply(shared) S.GROUT., ,,
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft' 27 ft• grout, pour
Non-Water Supply Well: '
[:Monitoring ❑Recovery
27 ft. 29 ft. bentonite pour
Injection Well: ft. ft. i
❑Aquifer Recharge 0 Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 29 ft. 35 ft. #2 Sand Pour
❑Aquifer Test ❑Stormwater Drainage -
ft. ft.
❑Experimental Technology 0 Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary), . .
❑Geothermal(Closed Loop) 0 Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
0 Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 3 ft. Silt
10/17/23 TW-3 3 ft. .7 ft. Fine sand
4.Date Well(s)Completed: Well ID#
7 ft. 14 ft. Fine sand
5a.Well Location: 14 ft. 20 ft. ! Coarse sand
Hop In Citgo 0-000000035884 20 ft. 35 ft. Fine sand
Facility/Owner Name Facility lD#(if applicable)
ft. ft.
1327 North Road Street, Elizabeth City, NC '
Physical Address,City,and Zip 21.REMARKS _ 'i'a per'+' ' i, V ?.._,4.I'
Pasquotank 8915-0460-8369 JAN 1 s 202.4
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:lni"" ?` C.57:4 '..r1 Ur'
(if well field,one lat/long is sufficient) D'vVr" ,(
36.329988 N 76.226721 W , 10/17/23
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA 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: 35 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tf d jerent(example-3@,200'and 2@100) construction to the following: I1
10.Static water level below top of casing: 5.07 (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
n 1 '
11.Borehole diameter: 6.25 - (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
Hollow Step Auger
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
I :
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 coup health department of the county where
constructed.
1
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013