GW1-2021-05349_Well Construction - GW1_20211013

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Charles N Dozier 14.WATER ZONES
Well Contractor Name
4088-A �'
,pr FROM TO DESCRIPTION
180 ft- 192 fL sand
ft. ft. i
NC Well Contractor Certification Number 1 ��\� 15.OUTER CASING for multi-cased wells OR LINER if a H ble
Toano Well and Pump Service In Je�S�n� FROM TO DIAMETER THICKNESS MATERLAL
ft. ft. in.
Company Name
\�t>i0(C� �tirlR 16.INNER CASING OR TUBING(geothermal ciosed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL.
List all applicable well construction permits(i.e.UIC,County,State,Variance.etc.) +2.5 ft• 180 ft• 4 in. SDR17 rve
3.Well Use(check well use): 190 ft' 195 ft- 4 in- SCH 40 Stainless steel
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ®MunicipaUPublic 180 ft• 190 ft. 4 in. 0.020 Stainless Steel
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
lndustrial/Commercial Residential Water Supply(shared) 18.GROUT
71 Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 175 ft. 0 ft. Well Grout DF Tremmie
Monitoring DRecovery
Injection Well:
fL ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL.PACK if applicable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage 195 ft• 176 ft• 93 Silica sand Tremmie
Experimental Technology 13Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional;sheets if necessary)
Geothermal(Heatin CooHn Return) Other(explain under#21 RemarkLJ
FROM TO DESCRIPTION color,hardness,soil/rack rain size,etc.
ft. fL SEE ATTACHED DRILL LOG
4.Date Well(s)Completed: 06/25/2021 Well ID#G15E2
5a.Well Location:
NCDENR
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
125 SANDY RIDGE ROAD, EDENTON, NC 27932 ft. ft.
Physical Address,City,and Zip it. ft.
Chowan 21.REMARKS
County Parcel Identification No.(PIM
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
36.1653706 N -76.6503383 W
Q7/14/2021
6.Is(are)the well(s)oPermanent or Temporary Signature of Cered 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: ®Yes or R)No with 15A NCAC 02C.0100 or 1 SA 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 of this farm.
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. SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 195 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi(jerent(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: 10 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
Mud Rotary 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-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

ADDITIONAL DRILL LOG:
Well Construction Permit #: G15E2
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
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