GW1-2021-05784_Well Construction - GW1_20211015

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple Hells
I.Well Contractor Information:
Todd Muench 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 5 ft' 12.5 ft' Wet
3371 ft. I ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: R. R. in.
0 2.5 sch40 pvc
List all applicable well permits(i.e.County.State.Variance.Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 2.5 "' 12.5 ft. 2 1n. .010 sch40 pvc
❑Geothermal(Heating/Cooling Coolin Supply) ❑Residential Water Su Iv sm le ft. ft. in.
( g PP Y) PP ( g )
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 5 fl. Portland Cem Tremie
Non-Water Supply Well:
ZMonitoring ❑Recovery .5 rr. 1 rr. Bentonite Chil Tremie
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ifa "ficible
.. FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity,Barrier 1 fr. 12 5 ft• #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage fit. 1"
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additioneil sbeets if necissit
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock e, rain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 4 ft• Concrete 4"thick-core 2 locations
9-23-21 MW-01 4 fr. 5 e• Fill Dirt
4.Date Well(s)Completed: Well ID# 5 fr. 12.5 ft• Tan, Grey,wet,sand and silt
5a.Well Location:
ft. ft.
Huntingquarters Fishhouse, LLC ft. ft.
Facility/Owner Name Facility ID4(if applicable) ft. ft. -
1050 Seashore Drive, Atlantic 28511 � 'e
ft. ft.
Physical Address,City,and Zip
21.REMARKS OCT 1
Carteret 749216825818000 4"FMC ,
k
County Parcel Identification No.(PIN) 11 i- 111 s.2u ¢t
N , r-Clir,F,
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22 C on:
(ifwetl field,one IaUlong is sufficient) `//
34.882460 N -76.336619 W ?a
Signature ofCertitied Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this Jbrnt, 1 herebv certtlt that the tee/l(s)was(were)constructed in accordance
frith 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Consiruction Standards and dun a
7.Is this a repair to an existing well: ❑Yes or E)No copy ofthis record has been provided to the well owner.
If this is a repair,Jill out knotrn ire11 construction inJbrmation and explain the nature of the
repair under=21 remarks section or on the back ty'lhi.s form. 23.Site diagram or additional well detail's:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For i ulliple injection or non-[rater supply wells ONLY with the same construction,You can
submit one,16rm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 12.5 (fr•) 24a. For All Wells: Submit this form within 30 days of completion of well
1•br multiple wells list all dept/ts 11'dii#erenu(example-3 a200'and 2 c@i/00') construction to the following:
10.Static water level below top of casing: 5 (ft.) Division of Water Resources,Information Processing Unit,
4grater level is abase caging,use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter- 2 (in.) 24b. For Infection Wells ONLY: In addition to sending the form to the address in
-s 1/4 HSA 24aabove, also submit a copy of this form within 30 days of completion of well
12.Well construction meth. 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&Injection Wells:
Also submit one copy of this font within 30 days ofcompletion of
13b.Disinfection type: Amount: 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