GW1-2022-05981_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 50 ft- 72 ft- White Limestone
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for moll;-cased wells OR LINER tf a licable)
Applied Resource Management FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
EHWP-00564-2021 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Cmmly,Slate,Variance,etc.) ft• ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) 52 ft 72 ft 4 1° 20 80 PVC
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 50 It- Bentonite Poured
Monitoring DRecovery ft. ft.
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 [DStormwater Drainage 50 ft. 72 ft. #2 Sand Poured
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soittrock e, rain size,etc.
0 ft. 10 ft- Orange clay and sand mix
4.Date Well(s)Completed: 1/6/2022 Well ID# 10 ft. 40 ft- Grey sandy silt
Sa.Well Location:
40 ft. 50 ft• Limestone shells, coarse sand
Coastal Realty 50 ft- 72 ft- White Limestone
Facility/Owner Name Facility IDtF(if applicable)
rt. ft
Lot 1 Union Bethel Road, Hampstead, NC 28443 ft ft.
Physical Address,City,and Zip ft. ft
Pender 4214-35-5717-0000 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: i ati,:isnr i t�i t rl;t.l:,i_J t1;'tit7 Ui\!
(ifwell field,one lat/long is sufficient) 22.Certification:
77 37 43.913 N 34 25 34.05 W 1/06/2022
6.Is(are)the well(s)oPermanent or 13Temporary Sig&urc of Certified Well Contractor Date
By signing this form,I hereby certi,that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [IYes or XJNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 1Vell 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 hots 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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 72 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For mudiple wells list all depths if different(example-3@200'and 1@100') construction to the following:
10.Static water level below top of casing: 12 (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: 7 7/8(in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12. Mud Rota above, also submit one copy of this form within 30 days of completion of well
Well construction method Rotary 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) 60 Method of test: Airlift 24c.For Water Sunaly&Injection 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: 20 o�0 completion of well construction fo 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