GW1-2022-03288_Well Construction - GW1_20220314

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
KENNY SARGENT 14.WATER ZONES i
FROM TO DESCRIPTION
Well Contractor Name
fr. ft. `
A - 4226 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
rt. ft. in.
Company Name
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) 0.0 ft. 5.0 ft. 2.0 in. SCH 40 PVC
3.Well Use(check well use): tt. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5.0 fr. 15.0 ft' 2.0 in.
.010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 3.0 ft' PORTLAND;aENTONITE SLURRY
(EMonitoring ❑Recovery
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM 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.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
m) ❑Other(explain under Remarks) FROM TO DESCRIPTION color,hardness,soil/rock a rain size,etc.
❑Geothermal(Heating/CoolingRetu
0.0 It. 1.0 fr. GRAVEL
4.Date Well(s)Completed: 1 1/16/21 Well ID# MW-13 1.0 ft. 6.0 ft• WHITE SAND
5a.Well Location: 6.0 f' 12.0 ft' BROWN SILTY SAND
CAMP LEJEUNE - SITE 9 12.0 ft• 15.0 ft• BLACK SILTY SAND
Facility/Owner Name Facility I Dl1(if applicable) ft. ft. �
2720 PINEY GREEN ROAD JACKSONVILLE 28547 ft. ft.
Physical Address,City,and Zip ft. ft. MAR 7
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:
(ifwell field,one lat/long is sufficient) 22.Certification:
340 43' 17.98" N 770 19' 15.28" W �lj l t,,,,,1, --- 11/23/21
6.Is(are)the well(s)• [EPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,/hereby certify that the irel/(s)was(here)constructed in accordance frith
7.Is this a repair to an existing well: ❑Yes or [!5No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
/fthis is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the smell owner.
repair under 021 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-I 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.)
1�ur muhiple wells list all depths if'dii ferent(example-3 r�200'and 1 cet 100')10. 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),
lllrater level is above casing,use"+Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lf "
11.Borehole diameter: 6.0 (in.) 24b. For Infection 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 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Ii
Form GW-I North Carolina Department of Etiviron nental Quality-Division of Water Resources Revised 6-6-2018