GW1-2022-05390_Well Construction - GW1_20220609

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NORTH CAROLINA
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WELL CONSTRUCTION RECORD (GW-1 )
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Form GW-1 Well Construction Electronic Form
North Carolina Department of Environmental Quality
Division of Water Resources
November1
Submission ID#
GW 1-2022-05390
Are you submitting a scanned form?* Yes
• No
CONTACT INFORMATION
.......................................................................................................................
Contact Name* Email Address*
Mike Hager [e-mail]
Is this a revision to the form you have previously submitted?*
Yes No
WELL CONSTRUCTION INFORMATION
........................................................................................................................................................................................................................................................................................................................................................................................................................................................
1.Who is installing these wells?*
Owner Well Contractor
1.Well Contractor Information:
Certiticate# Cert Level First Name Last Name Company Name
4261 A MICHAEL HAGER LLOYD WELL DRILLING
2.Well Construction Permit#:
365120
List all applicable well construction permits(i.e.Monitoring Wells,UIC-Underground Injection Control,CCPCUA-Central Coastal Plain Capacity Use Area,County,
etc.)
What type of well is this?* Injection Well Non-Water Supply Well
Water Supply Well(includes irrigation wells)
3.Water Supply Well* Geothermal (Heating/Cooling Supply) Industrial/Commercial
Irrigation Municipal/Public/Community
Residential Water Supply(single) Residential Water Supply(shared)
Wells> 100,000 GPD
4.Date well was completed and ID#
Date Well Completed* Well ID# Well Yield

6/2/2022 60
(gallons per minute)"
5.Well Location
.....................................................................................................
Facility/Owner Name*
Ashley Baxter Johnson c/o Sierra Baxter Facility ID#
(Required) (If applicable)
County*
Carteret
The selected county is within the Central Coastal Plain Capacity Use Area. Please reference your Capacity Use Water
Withdrawal Permit Number(CUxxxx)in Section 2.above.
Parcel Identification No.(PIN)
74921830637900
Physical Address* Street Address
621 Seashore Drive
Address Line 2
City State/Province/Region
Atlantic NC
Postal/Zip Code Country
28511 us
Latitude* 34.8760687000 Longitude*76.3531710000
Decimal degrees Decimal degrees
.....................................
6.Is(are)the well(s):* Permanent Temporary
7.Is this a repair to an existing well:* Yes • No
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this form.
For multiple Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction,only 1 GW-1 is needed.
8a.Indicate TOTAL NUMBER of wells drilled:
9.Total well depth below land surface: (ft.) 9a.What is the depth of the casing from ground
80 surface?
For multiple wells list all depths if different 70
(example-3@200'and 2@100') in feet
10.Static water level below top of casing: (ft.) 11.Borehole diameter:
5 4
If water level is above casing,use"+" in inches
12.Well construction method:
Auger Air Rotary Cable Tool
Direct Push Mud Rotary Rotosonic
Other
13. FOR WATER SUPPLY WELLS ONLY:

13a.Yield(gpm)
60 13a.Method of test:
If applicable Air Lift
13b. Disinfection type:* 13b.Amount:
Chlorine 2 oz
....................................................................
14.WATER BEARING/FRACTURE ZONES
From To Description
70 80 Sandstone/shells
in feet in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
From To Diameter Thickness Material
in feet in feet in inches
17.SCREEN
............................................................................................................................................................
From To Diameter Thickness Material
70.00 80.00 4.00 Sch 40 PVC
in feet in feet in inches
18.GROUT
...............................
From To Material Emplacment Method&Amount
0.00 10.00 Quik Grout Pump-3 bags
in feet in feet
19. SAND/GRAVEL PACK(if applicable)
From To Material Emplacment Method
65.00 80.00 Coarse Sand Pour
in feet in feet
20. DRILLING LOG
From To Description(color, hardness,soil/rock type,grain size,etc.)
0.00 10.00 Black organics&sand
in feet in feet
10.00 30.00 Sand/shells
in feet in feet
30.00 40.00 Sandstone/shells
in feet in feet
40.00 50.00 Sandy Blue Clay w/shells
in feet in feet
50.00 80.00 Sandstone&shells
in feet in feet
21. Remarks

22.Site diagram or additional well details:
You may upload additional well construction information here.
pdf only
CERTIFICATION INFORMATION
* By signing this form, I hereby certify that the well(s)was(were)constructed in accordance with 15A NCAC 02C.0100 or
15A NCAC 02C.0200 Well Construction Standards and that a copy of this record has been provided to the well owner.
23.Certification
Ake #dger
Signature of Certified Well Contractor