GW1-2021-02392_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
3497-A
35ft' 55f- sand, surficial
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
SUM TD DIAMETER THICKNESS MATERIAL
Applied Resource Management
ft. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-leo
2.Well Construction Permit#: EHWP-392-2021 FROM I TO DIAMETER TMCKNESS I MATERIAL
List all applicable well construction permits(i.e.VIC,County,State,Variance,etc.) ft. ft. t°•
3.well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER i BLOT SIZE THICKNESS MATERIAL
_ Agricultural ®Municipal/Public 35fc 55fL 4in• 10 PVC
]Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 38ft• Bentonite Poured
J Monitoring Recovery
Injection Well: ft. ft
_)Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
_,Aquifer Storage and Recovery OSalinity Barrier FROM TO I MATERIAL I EMPLACEMENT METHOD
J Aquifer Test OStormwater Drainage 35ft. 55ft. #2 sand Poured
_ Experimental Technology Subsidence Control ft. &
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
_1 Geothermal(Heating/Cooling Return) Other(explain under 421 Remarks) FROM TO DESCRIPTION color hardness soil/rock type,gmin size etc.
Oft. 10ft. sand
4.Date Well(s)Completed:07/09/2021 Well ID# 1 Oft. 20 ft- orange sand
5a.Well Location: 20 ft- 35ft• grey fine sand with clay
David Anderson 35ft. 40ft. Limestone sandstone mix VIN
Facility/Owner Name Facility iD#(if applicable) 40 ft. 55 ft. light grey sand �
533 Turkey Creek Rd. Rocky Point 28457 ft. ft.
Physical Address,City,and Zip ft. ft. 4
Pender 3223-14-7837-0000 21.REMARKS
County Parcel identification No.(PiN)
3u .
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
77 55 59 733 N 34 23 30 154w
07/09/2021
6.Is(are)the well(s)o`J Permanent or OTemporary Si mre of Certified well Contractor Date
By signing this form,I hereby certifv that the well(s)was(were)constructed in accordance
7:Is this a repair to an existing well: Oyes or DNo
`"- wi1"75A-,VCAC-02C.0700-r75A7VCAC102C.620b-3 e71Co`iasiruclion tan ads aa-d lhal -
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 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: 55(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@I00') construction to the following:
10.Static water level below top of casing: 5 Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,rise"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: $ (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) 10 Method of test: Air Lift 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: 1 0°�o completion of well construction to the county health department of the county
where constructed. i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016