GW1-2021-02442_Well Construction - GW1_20210901

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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 55f`- 75 fL 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, in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List al/applicable well construction permits(i.e.UIC,Comuy,Stale, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
J Agricultural [3Municipal/Public SSfL 75rL 4 in. 20 SCh 80 PVC
Geothermal(Heating/Coohng Supply) Residential Water Supply(single) ft ft in.
Industrial/Commercial rJ Residential Water Supply(shared) 18.GROUT
_')Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply well: Oft. 55ft• Bentonite Poured
:]Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK if a livable
( Aquifer Storage and Recovery OSalinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test []Stormwater Drainage 55ft• 75 ft- #2 Poured
Experimental Technology OSubsidence Control ft. ft.
i Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
I Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROMI To DESCRIPTION color,hardness,soil rock type,grain size,etc.
0 ft, 55 ft. sandy clay
4.Date Well(s)Completed: 08/09/2021 well ID# 55ff• 75 ft. gray course sand & shells
5a.Well Location: ft. ft.
Solstice Builders ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. r"N �..
1450 Turning Leaf Ln. Se Bolivia, 28422 f` f`
ft.
Physical Address,City,and Zip ft. t
Brunswick 203809070173 21.REMARKS
County Parcel Identification No.(PIN) - srrrrsSrtl ^ Lit"'
C;r.r�l;0I1
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �""�
(ifwell field,one lat/long is sufficient) 22.Certification:
33 59 14 N 78 14 29w 08/09/2021
6.Is(are)the well(s)'©Permanent or niTemporary S,46ature 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 ✓No with 15A NCAC 02C.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 hack 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: 75(ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
l%or multiple wells list al/depths ifderent(example-3@200'and 2@100') construction to the following:
i
10.Static water level below top of casing: 20 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 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
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) 60 Method of test: Air Lift 24c.For Water SunDly&Iniection 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: HtH Amount: 20�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 2-22-2016