GW1-2021-00131_Well Construction - GW1_20210615

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WELL CONSTRUCTION RE •RD ,
NORTH CAROLINA
EnWronmental Quullty
•rm GW-1 Well Construdon Electronic •
NorthCarolina Department of •
Di\Asion
April 1,2021
Page 1
Submission ID#
GW 1-2021-00131
CONTACT INFORMATION
..................................................................................................................................... .....................................................................
Contact Name* Email Address*
Mike Hager [e-mail]
Is this a revision to the form you have previously submitted?
f Yes r No
WELL CONSTRUCTION INFORMATION
.........................................................................................................................................................................................
1.Who is installing these wells?*
r Owner r Well Contractor
1.Well Contractor Information:
.............................................................................................................................................................................................
Certiticate# Cert Level First Name Last Name Company Name
4261 A MICHAEL HAGER LLOYD WELL DRILLING
2.Well Construction Permit#:
NW21-007
List all applicable well construction permits(i.e.Monitoring Wells,UIC,County,CCPCUA etc.)
What type of well is this?* r Injection Well r Non-Water Supply Well
r Water Supply Well(includes irrigation wells)
3.Water Supply Well* r Geothermal(Heating/Cooling Supply) r Industrial/Commercial
r Irrigation r Municipal/Public/Community
r Residential Water Supply(single) r Residential Water Supply(shared)
r Wells>100,000 GPD
4. Date well was completed and ID#
Date Well Completed* Well ID# Well Yield
6/11/2021 60
(gallons per minute)"

Page 2
5.Well Location
Facility/Owner Name*
Rodney Watson Facility ID#
(Required) (If applicable)
County*
Pamlico
The selected county is within the Central Coastal Plain Capacity Use Area. Please reference your Capacity Use Water
Withdrawal Permit Number(CLlxxxx)in Section 2.above.
Parcel Identification No.(PIN)
D061-161
Physical Address* Street Address
284 Chair Road
Address Line 2
City State/Province/Region
New Bern NC
Postal/Zp Code Country
28560-9147 US
Latitude* 35.1311412000 Longitude*76.9170330000
Decimal degrees Decimal degrees
6. Is(are)the well(s):* r Permanent r Temporary
7. Is this a repair to an existing well:* r Yes r No
If this is a repair,fill out known well construction information and a)plain the nature of the
repair under#21 remarks section or on the back of this form.
For multiple Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction,only 1 GW-1 is needed.
8a. Indicate TOTAL NUMBER of wells drilled:
9.Total well depth below land surface:(ft.) 9a.What is the depth of the casing from ground
190 surface?
Formultplewells Iistall depths if different 160
(example-3@200'and 2@100') in feet
10.Static water level below top of casing:(ft.) 11. Borehole diameter:
43 8x4
If water level is above casing,use"+" in inches
12.Well construction method:
r Auger r Air Rotary r Cable Tool
r Direct Push 6- Mud Rotary r Rotosonic
r Other
13. FOR WATER SUPPLY WELLS ONLY:

13a.Yield (gpm)
60 13a. Method of test:
If applicable Air Lift
13b. Disinfection type:* 13b.Amount:*
Chlorine 3 oz

Page 3
14.WATER BEARING/FRACTURE ZONES
From To Description
160 1 yu Limestone
in feet in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
From To Diameter Thickness Material
in feet in feet in inches
17.SCREEN
From To Diameter Thickness Material
160.00 190.00 2.00
in feet in feet in inches
18.GROUT
From To Material Emplacment Method &Amount
0.00 20.00 Quik Grout Pump-3 bags
in feet in feet
19.SAND/GRAVEL PACK(if applicable)
From To Material Emplacment Method
in feet in feet
20.DRILLING LOG
From To Description (color, hardness, soil/rock type, grain size,etc.)
0.00 10.00 Sand with little red clay
in feet in feet
10.00 50.00 Fine Sand
in feet in feet
50.00 70.00 Sandy blue clay
in feet in feet
70.00 110.00 Blue Clay
in feet in feet
110.00 128.00 Blue clay with streaks of sandstone
in feet in feet
128.00 160.00 Shellrock with streaks of clay
in feet in feet
160.00 190.00 Limestone
in feet in feet
21.Remarks

22.Site diagram or additional well details:
You may upload additional well construction information here.
pdf only
*PF 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 copy of this record has been provided to
the well owner.
23.Certification*
Ake Agge),-
Signature of Certified Well Contractor
Submittal Date 6/15/2021