GW1-2021-03675_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Matthew Thomas 14.WATER ZONES
Cunningham7 - FROM TO DESCRIPTION
Well Contractor Name .et�w . ft. ft.
a
NCWC 4217-A �^, .�" tc. ft.
NC Well Contractor Certification Number °" 15.0 ER CASING for multi-cased wells)OR LINER if a Gcable
L) F TO DIAMETER THICKNESS MATERIAL
Christian & Pugh Well Drilling p�C ' ra,€t' ft' 1 410 ft 4.5 in SDR-17 I PVC
Company Name 356005 �~'��.�i�J+`O FROMNER CASING OR TU DIAMETERhermaLTH CKNESS MATERIAL
2.Well Construction Permit#: v^>O� (�� 410 It' 530 1" 2 in. SCH 40 Galvanized
List all applicable well permits(i.e.County,State, Variance,Injection,etc.)
ft. It. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 530 "' 540 ft- 2 in. .020 Stainless
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
Dtndustrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Uri ation 0 rt. 20 l" Bentonite Poured
Non-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. fL
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage tt. fL
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness soiUrock type,grain sin,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 20 ft Top, Clay,Sand
4.Date Well(s)Completed: 8-4-2021 Well ID# 20 ft. 350 ft. Mud,Shell
350 ft- 370 ft. Black Sand
5a.Well Location: 370 rt• 410 ft. Mud, Clay
Frankie Lynn Hand 410 ft. 480 ft- Sand,Clays
Facility/Owner Name Facility ID#(if applicable)
TBD NC HWY 32 N., Corapeake, NC 27926 a8o ft. 5ao ft. sand
R. ft.
Physical Address,City,and Zip
21.REMARKS
Gates 7012145049000
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one IaOong is sufficient)
36 32 25.1 N -76 34 38.7 N 8-17-2021
ulir
i ature of CertifiedWel ontractor Date
6.Is(are)the well(s): [OPermanent or ❑Temporary
By signing this form,/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
7.Is This a repair to sa existing well: CYes or RINo copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: ONE construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 540 (rt,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 cCi 200'and 2 cei 100') construction to the following:
10.Static water level below top of casing: 62 (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 Infection Wells ONLY: In addition to sending the form to the address in,
Mud Rota 24aabove, also submit a copy of this form within 30 days of completion of well
12.Well construction method: ry 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
m 13a.Yield
(gP ) Method of test:
30+ Airlift 24c.For Water Supply&Inlection,Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Ca(ClO)2 Amount: 30 Ounces well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013