GW1-2021-02387_Well Construction - GW1_20210727

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
John Salmon 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
95f`- 11 Ft Limestone 'castle ha
3497-A ne aquifer
ft. ft.
NC Well Convector Certification Number 15.OUTER CASING for multi-cased wells OR LINER ita licable
Applied Resource Management FROM TO DIAMETER THICKNESS MATERIAL
ft. rt. in.
Company Name
16.INNER CASING OR TUBING eothermal closed-too
2.well Construction Permit#: E H WP-00382-2021 FROM I TO I DIAMETER I THICKNESS I MATERIAL
List all applicable well construchon permits(i.e.UIC,County,State,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
J Agricultural nMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
Industrial/Commercial �)Residential Water Supply(shared) 1s.GROUT
73 Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-water Supply well: 0 ft. 65 ft- Bentonite Poured
LJ Monitoring EIRecovery ft. ft.
Injection Well: ft. fr.
:]Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
J Aquifer Storage and Recovery E3Salinity Barrier FROM I To I MATERIAL EMPLACEMENT METHOD
J Aquifer Test [J Stormwater Drainage ft. rt.
Experimental Technology Subsidence Control ft. ft.
31 Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
[]Geothermal(Heating/Cooling Return) [3 Other(explain under 421 Remarks) FROM TO DESCRIPTION color,hardness soil/rock type,grain size etc.
0 e• 15 ft. white sand
4.Date Well(s)Completed: 07/15/2021 Well ID# 15 ft. 90 ft. clay silty sand
5a.Well Location: 90ft. 95ft• mixed sand and limestone
Travis Pollard 95 ft. 115 ft white!limestone
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Tract 15 Traders Neck Rd. Hampstead 28443 ft. ft.
Physical Address,City,and Zip ft. ft.
Pender 4216-24-5802_0000 21.REMARKS `'
County Parcel Identification No.(PIN) A�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: h(G rcn
(if well field,one lat/long is sufficient) 22.Certification
3428 11 N 77 37 53 w 07/15/2021
6.Is(are)the well(s):BPermanent or QlTemporary Si ture of Certified Well Contractor Date
/lv signing this form,I hereby ceriifv that the well(.)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or E No with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction 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-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: 115 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3@200'and 2@/00') construction to the following:
10.Static water level below top of casing: 20 (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: 5 5/8 (in.) 24b. For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method:
Mud Rotary above, also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
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 Sunoly& Injection Wells: In addition to sending the form to
o the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: l ltl-1 Amount: 0�o 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
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