GW1-2021-01568_Well Construction - GW1_20210309

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: RECEIVED
Sanford SWeeting 14.WATER ZONES
MAR X N 2021 FROM ft TO ft DESCRIPTION
Well Contractor Name L L
2082-A ft. ft.
Information Processing UIt
NC Well Contractor Certification Number
DWR Section 15.OUTER CASING for multi-casedwells ORLINER ifa licable
Applied Resource Management FROM TO DIAMETER THICKNESS MATERIAL
0 ft- 40 ft- 8 in- SCh 40 PVC
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)
2.Well Construction Permit#: EHWP-00397-2021 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.IIIC,County,State, Variance,etc) ft. ft. In.
3.Well Use(check well use): ft. tt. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
J Agricultural [J Municipal/Public 0 96 ft. 116 tt• 4 in 010 SCH 40 PVC
J]Geothermal(Heating/Cooling Supply) BResidential Water Supply(single) ft. ft.
J Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
7 lrrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 40 ft. Bentonite Pour
:31monitoring ❑Recovery 0.0 ft. 93 ft- Bentonite Pour
Injection-Well:
J Aquifer Recharge OGroundwater Remediation
19.SANDlGRAVEL PACK(if applicable)
Aquifer Storage and Recovery ❑ Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
J Aquifer Test [3Stormwater Drainage 93 rt• 116 ft-
]Aquifer Pour
:]Experimental Technology OSubsidence Control
Geothermal(Closed Loop) J Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soil/rock e, rain size,etc.
i_ Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) 0 0 ft. 30 ft.
Sandv silt some sand
4.Date Well(s)Completed: 02/17/2021 well ID# 30ft• 40ft• Clayey sand
5a.Well Location: 40 ft- 75ft• Broken limstone
James Cornette 75ft• 116ft• Hard limestone
Facility/Owner Name Facility ID#(if applicable)
111 Kingsport Dr. Hampstead, NC 28443
Physical Address,City,and Zip
Pender 3283-92-5546-0000 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Iat/long is sufficient) 22.Certification:
342255.83N 77 42 31.63 W �AZZ _) 03/03/2021
6.Is(are)the well(s)oPermanent or [3Temporary Signature of Yadified Well Contractor Date
- By signing"this fo`rrn,7 he y ce-fv X0 the we7lTi)-was were)-c'onsiruct-e-d-in accord
7.Is this a repair to an existing well: 13Yes or [allo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature ofthe copy ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 116 (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@200'and 2@100') construction to the following:
10.Static water level below top of casing: 6 (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: 7 7/8 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Mud Rota above, also submit one 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
13a.Yield(gpm) Method of test: 24c.For Water Supply& Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health epartment of the county
where constructed.
Farm OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016