GW1-2021-02803_Well Construction - GW1_20210601

'Prni Form""
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information-
d
Justin E. Nixon 14.WATER ZONES
Well Contractor Name o FROM TO DESCRIPTION
4265-A RED 336 ft- 352 ft- Medium Sand
ft. ft.
NC Well Contractor Certification Number 20M J U N 15.OUTER CASING for multi-cased wells OR LINER if a licable
Magette Well &Pump Co., Inc. U�jI FROM TO DIAMETER THICKNESS MATERIAL
ft.. & in.
Company Name B Q( " Dvvp,Cv`ectioC1
16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) +1 ft' 340 ft' 4.5 t"• SDR-17 PVC
3.Well Use(check well use): ft. fr. in.
17.
Water Supply Well: FROM SCREENTO DIAMETERSLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public 340 ft- 350 ft- 4 '"•I 0.020" sch 40 PVC
Geothermal(Heating/Cooling Supply) X,Residential Water Supply(single) ft ft. in•
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 5 ft• 330 ft• Quik-Grout Pump thru Tremie
3 Monitoring J Recovery 0 ft. 5 fr. hole plug Pour
Injection Well:
ft. fr.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
_ Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
J Aquifer Test DStormwater Drainage 330 ft- 357 ft- SP#2 Tremie
:3 Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) __J Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) i'Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soiUmck type,grain siz etc.
0 ft, 44 ft- Clay and Sand
4.Date Well(s)Completed:2-25-21 Well ID#Well Beside Pool 44 rr. 83 ' Blue Clay, some sand and shells
5a.Well Location: 83 rt• 87 ft• Very Hard Black Sandstone
Scott Lowe 87 ft. 104 rt- Black organics, Black sand
Facility/Owner Name Facility ID#(if applicable) 104 ft- 201 ft- Clay
232 Parkers Fishery Rd., Winton, NC 27986 201 It- 240 ft- Mostly clay some sand
Physical Address,City,and Zip ft. ft. Continued on back
Hertford 21.REMARKS
County Parcel Identification No.(PIN) Set on pit-less adapter. 15SQ10-250-3"complete unit-
set 200 feet of 1.25"sure align pvc drop pipe. 12/2 wire.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IaUlong is sufficient) 22.Can:
36.4144444 N 76.9486251 W ,f
3-1-21
6.Is(are)the well(s)oPermanent or OTemporary C41 "Igning
tore of Certified Well Contractor Date
this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: E)Yes or )No with 15A NCAC 02C.0100 or 15A NCAC 01C.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:1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 350 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing:75 (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: 8.75 (in.) 24b. For Infection Wells: In addition to sending the form to the address in 24a
Mud Rotary above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 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) 30 Method of test:Airlift 24c. For Water Supply& Infection 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: 8 oZ 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
E

20 DRILLING LOG"CONTINUED`
FROM TO DESCRIPTION
240 ft 264 ft Sand
264 ft 294 ft Mostly Clay,some sand
294 ft 336 ft Clay,sand increasing with depth
336 ft 352 ft Medium Sand
352 ft 356 ft Clay
356 ft 1 357 ft Clayey Sand