GW1-2021-05983_Well Construction - GW1_20211008

Pcint,Fo�m�;
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
John Salmon 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
36 fL 56 ft- sand shells layered clay
3497-A ft. ft.
NC Well Contractor Certification Number 1.5.OUTER CASING for multi-cased wells OR LINER if a' lieable'
Applied Resource Management FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name 16.INNER CASING OR TUBING eother a)closed-loo
2.well Construction Permit 4: 1992028056 FROM TO DIAMETER TMCKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICICNVESS MATERIAL
Agricultural (3Municipal/Public 36ft• 56rL 4in• 10 8 PVC
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Trri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water supply well: 0 ft• 36 ft. Bentonite Poured
Monitoring DRecovery
— Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
-19.SAND/GRAVEL PACK if a licable
Aquifer Storage and Recovery ©ISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormvvater Drainage 36 ft. 50 ft. #2 Sand Poured
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets ifnecessa
Geothermal(Heating/Cooling Return) 00ther(explain under 421 Remarks) FROM To DESCRIPTION color,hardness soil/rock a twin size etc.
0 ft. 10 ft. topsoil sand mix
4.Date Well(s)Completed: 09/20/2021 Well ID# 10 It. 30 ft. Grey Clay
5a.well Location: 30 fL 50 ft• shells with sand layered clay
Benny Cole 50ft• 60 fL Grey Clay
Facility/Owner Name Facility ID#(if applicable) ft. ft.
2039 Maco Rd. NE Leland 28451 ft. ft.
Physical Address,City,and Zip ft. ft.
Brunswick 216700169251 21.REMARKS
County Parcel Identification No.(PIN) Information Processing Unit
Section
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
341352.252N 78 80 067w �& 'sQAx,&"f' 09/20/2021
6.Is(are)the well(s)oPermanent or OTemporary Si a 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: nYes or ONo with 15A NCAC 02C.0100 or I5A NCAC(12C.0200 Well Construction Standards and/hat 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 i;11 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTION'S
9.Total well depth below land surface: 56 (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@100') construction to the following:
10.Static water level below top of casing: 15 (ft.) Division of Water Resources,Information Processing Unit,
lfwater 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
Mud Rota above, also submit one 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
13a.Yield(gpm) 40 Method of test: Air Lift 24c. For Water Supply& Iniectio 1 Wells: In addition to sending the form to
o the address(es) above, also submit lone copy of this form within 30 days of
13b.Disinfection type: HtH Amount: 20/o 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 Revised 2-22-2016