GW1-2021-03041_Well Construction - GW1_20210622

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: '
John Salmon „ w d 14.WATER ZONES
FROM TO DESCRIIMON
Well Contractor Name i
3497-A }1'J w 20�1 53ft 73ft Sand Limestone
r� c.nt ',ufiZhl ft. ft.
NC Well Contractor Certification Number r rnCn„'?'�;'
��1��f1�,attenl Cn^,tiCll IS.OUTER CASING' ftirmulti-cased wells)'ORLINER;ifa licable
Applied Resource Management p�ti t��=��` FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 53 ft. 4in SCh 40 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: EHWP-00299-2020 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. (11C County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
J Agricultural [3Municipal/Public 53ft 73 ft 4 i"' 20 SCh 40 PVC
Geothermal(Heating/Cooling Supply) EaResidential Water Supply(single) ft. ft. in.
Industrial/Commercial OResidential Water Supply(shared) 1S.GROUT
_ Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
— Non-water-snpplyWen: --_ Oft_ 20 ft. Bentonite ^Tremmie
_J Monitoring i Recovery ft. ft.
Injection Well: ft. ft.
J Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
J Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test nIJ StotmwaterDrainage 53ft 73 ft- 24 bags#2 gravel Poured
J
Experimental Technology OSubsidence Control ft. ft.
A Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
I Geothermal(Heating/Cooling Return) [:)Other(explain under 421 Remarks) FROM To DESCRIPTION color,hardness,soil/rock type,grain size,etc.
0 ft. 10ft. sandy soli
4.Date Well(s)Completed: 10/22/2020we11 ID# 1 Oft. 30ft• grey sandy soil
5a.Well Location: 30 ft. 60ft• sandy soil mix with layered shells limestone
Will Reeves 60ft• 80 ft. limestone
Facility/Owner Name Facility ID#(if applicable) 80ft. 85 ft. soft limestone
Lot 16 Pecan Grove Hampstead, NC 28443 ft. ft.
Physical Address,City,and Zip ft. ft.
Pender 4214-42-8579-0000 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutei/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
34 24 31 N 77 37 29 w 5a&o' 06/10/2021
- - 6-Is(are)-the well(s)oPermgneut-or �ITemporary
-- -S' ahveof-Certified-Well Contractor - - - -- - - Dater-------
By signing this farm,I hereby term that the well(,c)was(were)constructed in accordance
7.Is this a repair to an existing well: EIYes or ONo with 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this 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:
8.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 1 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: 73(ft•) 24a. For All Wells: Submit this fonn within 30 days of completion of well
For multiple wells list all depths if different(exannple-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 25 (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
above, also submit one cop),of this form within 30 days of completion of well
12.Well construction method: Mud Rotary 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
(gp ) 25 Guestimation 24c. For Water Supply& Infection Wells: In addition to sending the form to
13a.Yield m Method of test: g
° the address(es) above, also submitl one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: 3�° at Og completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016