GW1-2021-02445_Well Construction - GW1_20210901

l._ Print Form-
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
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John Salmon '�� .� 14.WATER ZONES
Well Contractor Name '�'c.-�" FROM TO DESCRIPTION
' ���1 55ft• 75 ft- limestone
3497-A Sty � �t�;;� ft. ft.
NC Well Contractor Certification Number r c
15.OUTER CASING for mtdH-cased wells OR LINER ifs licable
Applied Resource M ; FROM To TD DIAMETER THICKNESS MATERIAL
pp gpgg- v ft. ft. in.
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Company Name
16.INNER CASING OR TUBING(geothermal closed-too
2.Well Construction Permit#1: EHWp-00566-2021 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIC,County,State,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
Agricultural DMunicipal/Public 55 fL 75ft- 4 in. 20 Sch 80 PVC
Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
J Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply well: 0 ft. 55 ft. Bentonite Poured
Monitoring DRecovery ft. f.
Injection Well: ft. fa
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERw, EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage 55 ft. 75 ft. #2 Poured
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) MiTracer 20.DRILLING LOG attach additional sheets ifnecessa
I Geothermal(Heating/Cooling Return) DOther(explain under#t21 Remarks) FROM TO DESCRIPTION color,hardness soil/rock type,grain size,etc.
0 ft. 10ft• orange clay sand
4.Date Well(s)Completed: 08/26/2021 Well ID# 1 Oft. 40ft• grey sand silt
5a.Well Location: 40ft' 50ft' shells course sand
Matthew Sawyer 50ft• 75 ft- limestone
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Lot 2 Union Bethel, Hampstead 28443 ft. ft.
Physical Address,City,and Zip ft. ft.
Pender 4214-35-5668-0000 21.REMARK
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one[at/long is sufficient) 22.Certification:
77 37 43 295N 34 252 859 W IsQlneoz, 08/26/2021
6.Is(are)the well(s).✓1 Permanent or OTemporary Se ture of Certified Well Contractor Date
By signing this form,I hereby cerlifv that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or ONo with hA 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 imder 921 remarks section or on the back of 1his 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(f-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths it different(example-3@200'and 2@I00') construction to the following:
10.Static water level below top of casing: 12 (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: 8 (in.) 24b. For Infection Wells: In addition to sending the form to the address in 24a
Mud Rota above, also submit one copy of this form within 30 days of completion of well
]2.Well construction method: Rotary 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 Suonly& 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-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016