GW1-2021-00400_Well Construction - GW1_20210129

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
John Salmon 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
3497-A
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a Bcable
Applied Resource Management FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. I in.
Company Name 16.INNER CASING OR TUBING eotherma]closed-loop)
2.Well Construction Permit#: 241261 FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0 ft. 225 ft. 4 in. Seh 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
J Agricultural [3Municipal/Public 0225fL 245 fL 4 in- .010 SCh 40
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
_ Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 25 ft• bentonite poured
_._I Monitoring ❑Recovery 210 ft. 220 ft bentonite poured
Injection Well:
_ ft. ft.
Aquifer Recharge oGroundwater Remediation
19.SAND/GRAVEL PACK if a licabl8
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMI` CEI IENU METHOD
_I Aquifer Test ©IStormwater Drainage 220 ft. 245 ft. coarse sand poured
J Experimental TechnologySubsidence Control ft. ft.
J Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
J Geothermal(Heating/Cooling Return) J Other(explain under 421 Rernarks)j FROM TO DESCRIPTION color hardness soilfrock type,grain size etc.
0 f` 48 It- sandy clay to clay w/shell hash
4.Date Well(s)Completed: 1/13/2021 Well ID# 48 ft. 217 It. grey clay w/shell hash small sand lenses
5a.Well Location: 217 ft. 245 ft. limestone
Christian Weygoldt ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
210 Fox Run Lane ft. ft.
Physical Address,City,and Zip ft. ft.
Carteret 730703330702000 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
34 45 11.44 N 076 39 36.65 W ge� �'�� 01/22/2021
6.Is(are)the weil(s)oPermanent or OTemporary Signature Ccnified well Contractor Date
By signing this form,I hereby certfv that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or ®,No ^) with 75A NCAC 02C.0/00 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explatn7fie,itahtre of the copy of this record has been provided to the well owner.
repair under 921 remarks section or on the back of this form.R ? 4{'
a 23.Site diagram or additional well details:
�£�'�~ You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal� ells havin welar
construction,only 1 GW-I is needed. Indicate TOTAL NUM Is
eonstruction details. You may also attach additional pages if necessary.
drilled: JJ �`"' SUBMITTAL INSTRUCTIONS
r
9.Total well depth below land surface: ;1 ` (t) 24a. For All Wells: Submit this form within 30 days of completion of well
For•muhiple wells list all depths if different(example-3@200'aii2l'2@1011)'" construction to the following:
10.Static water level below top of casing: 1 (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: 8 (in.) 24b. For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method:
Mud Rotary above, also submit one copy of this form within 30 days of completion of well(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
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& Iniection 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 department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016