GW1-2021-06459_Well Construction - GW1_20211022

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
John Salmon 14.WATER ZONES t
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
45 65 sandy limestone
3497-A ft. ft.
NC Weil Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
Applied Resource Management FROM TO DIAMETER T1IICI4NE55 MATERIAL
pp 9 ft. ft. I in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: OSWPWP-20-014 FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Slate, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
J Agricultural OMunicipal/Public 45fL 65ft- 4 in• �O 80 pvc
,Geothermal(Heating/Cooling Supply) BResidential Water Supply(single) ft. ft. in.
Industrial/Commercial (.J Residential Water Supply(shared) 18.GROUT
l��irrl at10n FROM TO MATERIAL EMPLACEMFNT METHOD&AMOUNT
Non-Water Supply wen: 0 ft 35 ft bentonite poured
J Monitoring CI Recovery
Injection Well:
1 Aquifer Recharge ❑GroundwaterRemediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
_3J Aquifer Test OStormwater Drainage 35ft• 65 ft- #2 sand poured
Experimental Technology Dl Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color•,hardness,soil/rock e, rain size,etc.
I Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) Oft• 30ft. sand with clay layers
4.Date Well(s)Completed: 10/06/2021 Well ID# 30ft• 35 ft- grey sand
5a.Well Location: 35 ft- 65 ft• sandy limestone with shells
Donald Miller ft. I
ft.
Facility/Owner Name Facility iD#(if applicable) ft. ft.
3850 Northeast Ave. Castle Hayne 28429 ft. fL a'
Physical Address,City,and Zip
New Hanover RO1100-017-013-000 21.REMARKS
County Parcel identification No.(PiN) I ` It
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Iattlonb is sufficient) 22.Certification: t J ~CIN l vJ`J
3421 46 N 77 54 11 W � 'SQAe'�Z' 10/06/2021
6.Is(are)the well(s)oPermanent or [;Temporary S afore of Certified Well Contractor Date
By signing this form,I hereby cerlifv that the we/l(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or MNo with 15A NCAC 02C.0100 or 15A NCAC'02C.0200 Well Construction Standards and that a
1f lhis is a repair,fill out known well construction information and explain the nature of/he copy of this record has been provided to the well owner.
repair under#21 remarks section at-on the hack 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 INSTRUCTIONS
9.Total well depth below land surface: 65 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2 ct,100') construction to the following:
10.Static water level below top of casing: 8 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,rise"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 7 7/8 (in.
24b. For Iniection 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: Rotary 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 2 769 9-1 636
13a.Yield(gpm) 40 Method of test: Air Lift 24c. For Water Suouly& Iniection Wells: In addition to sending the form to
D the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HtH Amount: 20/0 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