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HomeMy WebLinkAboutGW1-2021-06461_Well Construction - GW1_20211022 IF Print Form WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: 1.Well Contractor Information: John Salmon 14.WATER ZONES Well Contractor Name FROM TO DESCRIPTION 3497-A 45f` 65ft- sandy limestone ft. ft. NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable Applied Resource Management FROM TO DIAMETER THICKNESS MATERIAL: ft. ft I in. Company Name 16:INNER CASING OR TUBING eothormal closed-too 2.Well Construction Permit#: OSWPWP-20-014 FROM TO DIAMETER THICKNESS MATERIAL List all applicable well construction permits(i.e.111C,County,Slate,Variance,etc.) ft. ft. in. 3.Well Use(check well use): ft. ft. in. Water Supply Well: 17.SCREEN FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL _1 Agricultural DMunicipal/Public 45fL 65ft. 4 in. 10 SO PVC Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft. ft. in. Industrial/Commercial DResidential Water Supply(shared) 18.GROUT __]Irrigation ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT Non-Water Supply Well: 0 ft. 35 ft- bentonite poured Monitoring ❑Recovery ft. ft. ---Injection Well: _ 'ft. ft. Di Recharge Groundwater Remediation 19.SAND/GRAVEL PACK if applicable) _i Aquifer Storage and RecoverySaliniry Barrier FROM TO MATERIAL I EMPLACEMENTMETHOD I Aquifer Test DStormwater Drainage 35ft• 65 ft• #2'Sand poured Experimental Technology DJ Subsidence Control ft. ft. I Geothermal(Closed Loop) DJ Tracer 20.DRILLING LOG attach additional sheets if necessa J _Geothermal(Heating/Cooling Return) Other(explain under 421 Remarks) FROMI TO DESCRIPTION(color,hardness,soil/rock type, ain size,etc. Oft. 30ft• sand with clay layers 4.Date Well(s)Completed: 10/06/2021 Well ID# 30ft• 35 ft. grey sand Sa.Well Location: 35 ft. 65 ft. sandy d .'limestone with , Donald Miller ft fLv �°'� Facility/Owner Name Facility ID#(if applicable) ft. ft. 3850 Northeast Ave. Castle Hayne 28429 ft. ft, Cj Physical Address,City,and Zip ft. ft. New Hanover R01100-017-013_000 21.REMARKS Yr County Parcel Identification No.(PIN) 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (ifwell field,one lat/long is sufficient) 22.Certification: 34 21 46 N 77 54 11 W I aAxe Z 10/06/2021 6.Is(are)the well(s)IDPermanent or OTemporary 801ature 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: Dyes or [allo nWh 15A NCAC 02C.0100 or 15A NCAG 02C.0200'Well Construction"Standards and that a 1f 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 921 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 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: 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@100') construction to the following: 10.Static water level below top of casing: 18 (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 Iniection Wells: In addition to sending the form to the address in 24a Mud Rotaryabove, 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) 40 Method of test: Air Lift 24c. For Water Slimily& Iniection Wells: In addition to sending the form to the address(es) above, also submitj one copy of this form within 30 days of 13b.Disinfection type: HtH Amount: 20 o�o 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 2-22-20I6