GW1-2022-05979_Well Construction - GW1_20220617

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
John Salmon 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3497 -A 62 f`' 82 "' Lime Stone
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable)
ARM FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name 16.INNER CASING OR TURING(geothermal closed-loop)
2.Well Construction Permit#: EHWP-681—2021 FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County.Slate,variance,etc) 0 ft. 72 1" 2 in. SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft. in.
72 g7 2 .020 SCH 40 PVC
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
�IndustriaUCommercial DResidential Water Supply(shared) 18.GROUT
_ lrrt ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 68 ft. Bentonite Chips Poured
Monitoring EIRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK ifa licable
Aquifer Storage and Recovery [ISalinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage 68 ft. 87 ft- #2 Sand Pour
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soil/mck e, rain size,etc.
Geothermal(Heating/Cooling Return) .Other(explain under#21 Remarks)
0 ft. 20 ft. Sand
4.Date Well(s)Completed:01/15/2022 Well ID# 20 "• 62 f` Clay with Sand Layers
5a.Well Location: 62 ft• 72 ft* Soft Limestone
James Fuller 72 f" 87 ft.
Lime Stone
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
110 Fuller Lane ft. ft. 5;" t. � `1
„r t li S
Physical Address,City,and Zip ft. ft. '
Pender 4214-08-6865-0000 21.REMARKS
County Parcel Identification No.(PIN) _
u'� :rl�.�i+iltitta
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Wi
(ifwell field,one Iattlong is sufficient) 22.Certification:
340 25'33.15" N 77° 38'16.75" W
6.Is(are)the well(s)JIPermanent or Temporary S ignae of Certified Well Contractor Date
By signing this form,I hereby cerl fi,that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: rlIYes or MNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,full out known well construction injornation and explain the nature of the copy of this record has been provided to the well owner.
repair under#2I renarks section or an the hack o(lhis 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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 87 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For mul iple wells list all depths ifdijjereni(example-3 tt 200'and 2@100') construction to the following:
10.Static water level below top of casing: 1 5 (ft.) Division of Water Resources,Information Processing Unit,
Ifivaler level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
MudRotary 12.Well construction method:
Rota above,also subunit 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) 25 Method of test: Air Lift 24c. For Water Supply&Iniection 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: 1# completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016