GW1-2021-07954_Well Construction - GW1_20210809

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Thomas Whitehead 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name fL fL
2907-A
NC Well Contractor Certification Number 15.OUTER CASING for multFpsed wells)OR:LINER a ticable
FROM TO DIAMETER T�CIINFM MATERIAL
S&ME INC It• I IL in.
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
E17.
TO DIAMETER IMCKNFSS MATERIAL
2.Well Construction Permit#: ft. 10 It• 1 1a Sch 40 PVC
List all applicable well permits(i.e.County,Stale,Variance,Injection,etc.) in.
ft. ft.
3.Well Use(check well use): REEN
Water Supply Well: TO DIAMETER SLOT SITE TBICKNM MATERIAL
❑Agricultural ❑Municipal/Public 10 It. 20 IL 1 In. .010 SCh 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) N. n- in.
'.
❑IndustriaV 18.GROUTCOmmerclal ❑Residential Water Supply(shared) FROM TO MATERIAL' EMPLACEMEI\T METHOD&AMOUNT
Oftrigation U rt. 6 IL, Cement Pour.
Non-Water Supply Well:
RMonitoring ❑Recovery 6 tt 8 tt. Bent011lte Pour
Injection Well ft. fL
[]Aquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVEL PACK applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery []Salinity Barrier .ft IL 8 20 #2 Sand I Pour
OAquifer Test OStormwater Drainage fL ft,
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets If necess
[]Geothermal(Closed Loop) []Tracer FROM TO DESCRIPTION color,hardness,solurock tyM grain W-
❑Geothermal(Heating/Cooling Return) ❑other(explain under#21 Remarks) 0 it. 8,0 ft Tan Fine Sand
7/30/21 MW-1 8.6 ,t. 17.0 fL Brown Silty Sand
4.Date Well(s)Completed: Well ID# 17.0 n 20.0 a Tan Clayey Sand
5a.Well Location: g• fL
R. It. +
Facility/Owner Naroc Facility ID#(if applicable) ft. ft.
11401 US-17 Wilmington NC R• yaw
Physical Address,City,and Zip 21.REMARKS'
Pender
County Parcel Identification No.(PIN) r
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: '
22.Certification:
(ifwell field,one lavlong is sufficient)
34.332012 N 777.750735 W 8/2/21
Signature of Certified Well Contractor Date
6.Is(are)the well(s): 2Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)wns(we're)constructed in accordance
with 1 SA NCAC 02C.0100 or 15A NCAC 02C:0100 Well Construction Standards and thara
7.Is this a repair to an existing well: ❑Yes or E]No copy of this record has been provided to the well owner.
lfthis is a repair,fill out known well'construction information and explain the nature of the
repair under#11 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page:to provide additional well site details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple Injection or non-water supply wells ONLY with the same consirucdon,you can
submit one form. SUBMITTAL INSTUCTIONS
20.0 24a. For All Wells: Submit this form within 30 des of completion of well
9.Total well depth below land surface: (ft.) days P
For multiple wells list all depths if different(example-3Q200'and 2Q1001 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: .6.0 (in:) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
Rotary 24a above,also submit a 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&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013