GW1-2021-06280_Well Construction - GW1_20210915

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
John Salmon 14.WATER ZONES
Well Contractor Name
FROM ft TO ft. DESCRIPTION
J�
1 �y��9
3497-A C.0�� o� ft. ft.
NC Well Contractor Certification Number ,15.OUTER CASING for multi-cased wells OR LINER if a lieable
Applied Resource Managemegw�o,.'3 � FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit 4: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. UIC,County,Slate, Variance,etc.) 0 ft. 300 ft- 1 in. SDr 11 HDPE
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural r-IMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
J Industrial/Commercial Residential Water Supply(shared) t8.GROUT
_]Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 300& Tremmie Pipe
:]Monitoring_., .__ DRecovery ft.. ft.. l ,
Injection Well: ft. f.
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
_ Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL EMPLACEntEV7 METHOD
J Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft
3I
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soil/rock e, rain size etc.
!Geothermal(Heating/Cooling Return) _ Other(explain under#t21 Remarks)
Oft' 55ft• sandy clay
4.Date Well(s)Completed: 08/10/2021 well ID# 55 ft- 80ft• grey sand and shells
5a.Well Location: 80ft• 300 ft• thin layered limestone with heavy grey clay
Fulford Heating &Air ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1450 Turning Leaf Ln. Se Bolivia, 28422 ft. ft.
Physical Address,City,and Zip
ft. ft.
Brunswick 203809070173 21.REMARKS
Cotmty Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one IatAong is sufficient) 22.Certification:
See Attached N w !Ya,64N 08/30/2021
6.ls(are)the wells) ✓Permanent or OTemporary Viature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or allo with 15A NCAC 02C.0100 or 15A AtCAC 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 m the well owner.
repair under#21 remarks section at,on the hack 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:2 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 300(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@I00') construction to the following:
10.Static water level below top of casing: (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: 5 7/8 (in.) 24b. For Injection 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: 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 SuoDly& Injection 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 j Revised 2-22-2016
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