GW1-2022-03287_Well Construction - GW1_20220314

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
KENNY SARGENT 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
ft.A - 4226 ft.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. I in.
Company Name
16.INNER CASING OR TUBING eothermal'closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable hell construction permits(i.e.UIC,County,Slate,Variance,etc) 0.0 ft- 5.0 ft- 2.0 in. SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
OAgricultural ❑Municipal/Public 5.0 ft' 15.0 ft' 2.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft f. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
Dlrri ation ❑Wel Is> 100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 3.0 ft. PORTLANDSENTONRE SLURRY
OMonitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 4.0 ft- 15.0 ft 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
OGeothennal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) OOther(explain under#21 Remarks) FROM I TO DESCRIPTION color,hardness soil/rock type,grain sin,etc.
0.0 ft. 1.0 It. GRASSfFOPSOIL
4.Date Well(s)Completed: 11/15/21 Well ID# MW-14 1.0 It• 6.0 It. WHITE SAND
5a.Well Location: 6.0 It• 12.0 It' BROWN SILTY SAND
CAMP LEJEUNE - SITE 9 12.0 ft. 15.0 ft- BLACK SILTY SAND
Facility/Owner Name Facility ID#(if applicable) ft. ft.
I
2720 PINEY GREEN ROAD JACKSONVILLE 28547 fr. ft.
Physical Address,City,and Zip ft, ft. MAR 202'
ONSLOW 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-3.0-4.0 FEET .
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
340 43' 17.51" N 770 19' 15.35" W 11/23/21
6.Is(are)the well(s): IflPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this forin,l hereby certify that the well(s)was(were)c•onsirucved in ac•c•ordanc•e with
7.Is this a repair to an existing well: ❑Yes or CENo I5A NCAC 02C.0/00 or 15A NCAC 02C.0200 Well Consiruction Standards and that a copy
U this is a repair,fi//out known well construction information and explain the nature oJ'the 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 construction info
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 15.0 (ft.)
Fihr muhiple wells list al/depths ifdiffereni(exanhple-3@200'and 2@/00') Submit this GW-1 within 30 days of well completion per the following:
10.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: 6.0 (in.) 24b. For Injection Wells:Copy to DWR,Underground Injection Control (IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: SONIC
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing�over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-161 1
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Fonn GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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