GW1-2021-02446_Well Construction - GW1_20210901

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
John Salmon o.1 _ -� 14.WATER ZONES
Well Contractor Name i �3 `y FROM TO DESCRIPTION
,. 55 ft- 75ft.
3497-A ,� 2�Z1 limestone
ft. ft. I
NC Well Contractor Certification Number %3`, 15.OUTER CASING for multi-cased wells OR LINER if a licable
a-il1J UI�I FROM TO DIAMETER THICKNESS PATERIAL
Applied Resource Management ;„�,t'.-` '`
ft. ft. in.
Company Name ��r''' "
16.INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit 4: EHWP-00564-2021 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction 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 FIMunicipaUPublic 55 fL 75 ft- 4 in. 20 Sch 80 PVC
:]Geothermal(Heating/Cooling Supply) Gi Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
_ Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-water supply Well: o ft. 55 ft- Bentonite Poured
Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
J Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
J Aquifer Test E]Stormwater Drainage 55 ft- 75 ft- #2 Poured
Experimental Technology OSubsidence Control ft. ft.
1 Geothermal(Closed Loop) nTracer 20.DRILLING LOG attach additional sheets ifnecessa
Geothermal(Heating/Cooling Return) []Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grain size etc.
oft' 1 oft' orange clay sand
4.Date Well(s)Completed: 08/26/21 well ID# 10fl- 40ft• grey sand silt
5a.Well Location: 40ft- 50ft- shells course sand
Matthew Sawyer 50" 75ft• limestone
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
Lot 1 Union Bethel Rd. Hampstead, 28443 f` ft.
Physical Address,City,and Zip ft. ft.
Pender 4214-35-5717_0000 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one[at/long is sufficient) 22.Certification:
77 33 43 918 N 34 253 405 Wg�'.� �Q .'Z' 087/26/2021
6.Is(are)the well(s)V1 Permanent or OTemporary S ature of Certified Well Contractor Date
By signing dtis form,I hereby ceriifv that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DJ Yes or QNo with 15A AICAC 02C.0100 or I5A NCACO2C.0200 Well Consimction,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 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 I 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: 75 M-) 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@100') construction to the following:
10.Static water level below top of casing: 12 Division of Water Resources,Information Processing Unit,
lfwater level it above casing,use'•+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8 (in.) 24b. For Injection 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) 60 Method of test: Air Lift 24c. For Water Supply& Iniectitin 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/e completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Enviroamental Quality-Division of Water Resources Revised 2-22-2016