GW1-2021-02187_Well Construction - GW1_20210721

l____--Print Form
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Don Cummings 14.WATER ZONES
Well Contractor Name , FROM TO DESCRIPTION
Y ft. ft.
2412-A ft. ft.
NC Well Contractor Certification Number 11 I L ` 15.OUTER CASING for multi-cased wells OR LINER if a licable
Applied Resource Management Unit
T° DIAMETER; - TH'C'°"ESS MATERIAL
V ft. ft. in.
Company Name lnlofma l
ai
Div R 818e>:on 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit 4: FROM DIAMETER THICKNESS MATERIAL
To
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) 0 f`. 150" 4" SCh 40 PVC
3.Well Use(check well use): 140ft• 190 ft. 2 in' SCh 40 PVC
17.
Water Supply Well: FROM SCREENTO DIAMETER SLOT SIZE THICKNESS MATERIAL
J Agricultural �Municipal/Public 190ft- 210 fL 12'"' .010 Sch 40 PVC
_,Geothermal(Heating/Cooling Supply) E3Residential Water Supply(single) ft. ft. in.
Industrial/Commercial iOJ Residential Water Supply(shared) 18.GROUT
��Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply well: 0 ft. 150 e. Bentonite Poured
Monitoring _i Recovery ft. ft.
Injection Well:
ft. ft.
!Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
_!Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL. EMPLACEMENT DIETHOD
_!Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
:!)Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
-1 Geothermal(Heating/Cooling Return) _ Other(explain under#21 Remarks) FRont To DESCRIPTION color,hardness soil/rock type,grain size,etc.
Oft' 35ft• sands to sandy clay
4.Date Well(s)Completed:06/22/2021 Well ID# 35ft' 45ft• shells/;weathered limestone
5a.Well Location: 45 ft. 601 limestone clay mix
Jimmy Wilder 60 ft- 128f` limestone
Facility/Owner Name Facility ID#(if applicable) 128ft- 158ft• clay/mud rock sand layers
2110 Washington Acres Rd. Hampstead 28443 158f`- 190ft• sandy sandstone
Physical Address,City,and Zip 190 fL 210fi. harder sandstone
Pender 3291-06-9383-0000 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.Certification:
34 20 14.59 N 077 42 16.24 W 07/06/2021
6.Is(are)the well(s)•✓i Permanent or J Temporary Signature of Certified Well Conti or Date
`- - - --�-- _ ------- --- ---- _-Hv srg'ninX form;I heieb}�cent drai-ih we7l(s)was(were)constructed in accordance - - -
7.Is this a repair to an existing well: DYes or DNo with 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Consnwction 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 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-I 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: 21 0(ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') 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
r
11.Borehole diameter: 8 (in.) 24b. For Infection Wells: In addition to sending the form to the address in 24a
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 SUDDIV& Injection 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: HTH Amount: 3% at 10g completion of well construction to'i 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