GW1-2021-01197_Well Construction - GW1_20210902

�wn
WELL CONSTRUCTION RE •RD ,
NORTH CAROLINA
EnWronmental Quullty
•rm GW-1 Well Constructon Electronic •
North Carolina Department of En\Aronmental Quality
April 1,2021
Submission ID#
G W 1-2021-01197
Are you submitting a printed form?* r Yes
r No
CONTACT INFORMATION
.........................................................................................................................
Contact Name* Email Address*
Jimmy Morris [e-mail]
Is this a revision to the form you have previously submitted?
r 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
4193 A JIMMY MORRIS MAGETTE WELL&PUMP COMPANY,
INC.
2.Well Construction Permit#:
PWS2021-100637
List all applicable well construction permits(i.e.lVbnitoring Wells,UIC,County,CCPCUA etc.)
What type of well is this?* f Injection Well f 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

8/17/2021 60
(gallons per minute)"
5.Well Location
Facility/Owner Name
Kevin Rawls Facility ID#
(Required) (If applicable)
County*
Beaufort
The selected county is within the Central Coastal Plain Capacity Use Area. Please reference your Capacity Use Water
Withdrawal Permit Number(CUxxxx)in Section 2.above.
Parcel Identification No. (PIN)
Physical Address* Street Address
5282 Clarks Neck Rd
Address Line 2
City State/Province/Region
Washington NC
Postal/ZZp Code Country
27889 USA
Latitude* 35.5850460000 Longitude*-77151469.0000000000
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: 1
9.Total well depth below land surface:(ft.) 9a.What is the depth of the casing from ground
175 surface?
Formultiplewells listall depths if different 143
(example-3@200'and 2@100') in feet
10.Static water level below top of casing:(ft.) 11. Borehole diameter:
8 9.875
If water level is above casing,use"+" in inches
12.Well construction method:
r Auger r Air Rotary r Cable Tool
r Direct Push r 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:*
12%Sodium Hypochlorite 2 Gallons
......................................................................................................
14.WATER BEARING/FRACTURE ZONES
From To Description
143 175 fine black sand with some course quarts sand
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
143.00 175.00 4.00 Sch 40 PVC
in feet in feet in inches
18.GROUT
From To Material Emplacment Method &Amount
0.00 120.00 Bentonite Tremie
in feet in feet
19.SAND/GRAVEL PACK(if applicable)
From To Material Emplacment Method
120.00 178.00 SIP#2 Tremie
in feet in feet
20.DRILLING LOG
From To Description (color, hardness,soil/rock type,grain size,etc.)
0.00 14.00 Sand
in feet in feet
14.00 33.00 Gray clay and shells
in feet in feet
33.00 42.00 Limestone
in feet in feet
42.00 60.00 Limestone,white clay with black sand
in feet in feet
60.00 65.00 limestone
in feet in feet
65.00 72.00 Gray clay, black sand,shells
in feet in feet

72.00 77.00 shells,gray clay with black sand
in feet in feet
77.00 81.00 sand
in feet in feet
81.00 83.00 limestone
in feet in feet
83.00 94.00 stiff black gray clay
in feet in feet
94.00 95.00 rock
in feet in feet
95.00 118.00 stiff black gray clay
in feet in feet
118.00 119.00 rock
in feet in feet
119.00 136.00 gray clay
in feet in feet
136.00 142.00 green sandy clay
in feet in feet
142.00 178.00 fine black sand with medium course quarts sand
in feet in feet
178.00 182.00 gray clay
in feet in feet
21.Remarks
22.Site diagram or additional well details:
You mayupload additional well construction information here.
pdf only
CERTIFICATION INFORMATION
........................................... ..............................................
*rJ 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*
'T'IRIAY MDf'r a
Signature of Certified Well Contractor
Submittal Date 9/2/2021