GW1-2021-05348_Well Construction - GW1_20211013

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Charles N Dozier fig, ��inL 14.WATER ZONES
Well Contractor Name dam'0 FROM TO DESCRIPTION
ft. fL
4088-A T 1
ft. ft.
NC Well Contractor Certification Number
Toano Well and Pump Service I II"�t.fln{�rC,essing Unit '15.OUTER CASING for mold cased wells PRUNER if a licable
FROM TO DIAMETER TffiCIatESS MATERIAL
®UDR SQL ion 0 ft. 12 it' 10 in' SCH40 PVC
Company Name
G 15E 1 16.INNER CASING'OR TUBING eotherinal'close8�dd
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State.Variance,etc) +2.5 fi- 310 ft. 4.5 in. SDR 17 vvc
3.Well Use(check well use): 320 ft- 325 ft. 4 in' SCH 40 Stainless Steel
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SI2E THICKNESS MATERIAL.
Agricultural [3Municipal/Public 310 ft, 320 ft. 4 in. 0.020 Stainless Steel
Geothermal(Heating/Cooling Supply) 13Residential Water Supply(single) tt. ft. in.
IndustriallCommercial Residential Water Supply(shared)
18.GROUT
' Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 305 ft. 0 ft. WEII Grout DF Tremme
Monitoring Recovery tt. ft.
Injection Well: ft ft
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage 330 ft- 305 ft, #3 Silica sand Tremmie
Experimental Technology 13Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heatin Coolin Return) ClOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grains etc.
ft. ft- SEE ATTACHED DRILL LOG
4.Date Well(s)Completed:06/25/2021 Well ID#G15E1 ft. ft.
ft. ft.
Sa.Well Location:
NC DENR
Facility/Owner Name Facility ID#(if applicable)
ft. ft
125 SANDY RIDGE ROAD, EDENTON, NC 27932 ft. ft.
Physical Address,City,and Zip ft. ft.
Chowan 21.REMARKS '
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lavlong is sufficient) 22.Certification:
36.1655018 N -76.6504171
W _A A r 07/14/2021
6.Is(are)the well(s)OPermanent or Temporary SibdlK of Certified W 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 R)No with 15A NCAC 02C.0100 or 15A 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 ofthis 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.
filled' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 325 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiJferent(example-3@200'and 2@100) 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: 10 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
Mud Rortary above, also submit one copy 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 Supply&Iniection 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-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
1

ADDITIONAL DRILL LOG:
Well Construction Permit #: G15E1
D.F. WALKER ELEMENTARY SCHOOL
125 Sandy Ridge Road
Edenton, NC 27932
FROM: TO: DESCRIPTION
0 FEET 10 FEET ORANGE SAND
10 FEET 30 FEET BLUE CLAY, SHELLS AND SAND MIX
30 FEET 40 FEET BLUE AND BROWN CLAY
40 FEET 50 FEET GREEN CLAY WITH SAND AND SHELL
50 FEET 60 FEET BLUE CLAY WITH SAND AND SHELL
60 FEET 80 FEET SHELL AND SAND
80 FEET 90 FEET CEMENTED FORMATION
90 FEET 100 FEET SHELL MATERIAL
100 FEET 110 FEET HRD ROCK AND SHELL FORMATION
110 FEET 120 FEET SHELLS AND SAND
120 FEET 130 FEET GREEN CLAY, SHELLS AND SAND
130 FEET 140 FEET GREEN CLAY, SHELLS AND SAND
140 FEET 150 FEET SHELL AND BLACK SAND
150 FEET 160 FEET BLUE CALY, SHELLS AND SAND
160 FEET 170 FEET BLUE CLAY, SHELLS AND SAND MIX
170 FEET 180 FEET SAND AND SHELL
180 FEET 190 FEET LIMESTONE ROCK
190 FEET 200 FEET GREEN CLAY
200 FEET 210 FEET GREEN CLAY
210 FEET 220 FEET GREEN SILTY CLAY
220 FEET 230 FEET GREEN SILTY CLAY
230 FEET 240 FEET SILTY CLAY AND SHELL MIX
240 FEET 260 FEET GREEN SILT AND SHELL
260 FEET 270 FEET BLUE AND GREEN CLAY
270 FEET 300 FEET BLACK SAND
300 FEET 310 FEET SAND AND SHELL
310 FEET 330 FEET BROWN SHELL
i