GW1-2022-05982_Well Construction - GW1_20220617

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
John Salmon 14.WATERZONES
Well Contractor Name FROM TO DESCRIPTION
3497-A 55 ft- 75 ft. White limestone mixed with sand
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable)
Applied Resource Management FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
EHWP-00566-2021 16.INNER CASING ORTUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO I DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,Countv.State,Variance,etc) +1 ft. 55 ft. 4 in. 1 80 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 0Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) 55 ft. 75 ft. 4 in. 20 80 PVC
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
'Irrigation
on-Water Supply Well: 0 ft. 50 ft. Bentonite Poured
Monitoring Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge E3Ground,.vater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM I TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage 50 ft. 75 ft. #2 Sand Poured
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiVmck typt,,grain siu,etc.
0 ft. 10 ft. Orange clay sand
4.Date Wells)Completed: 1/05/2022 Well ID# 10 ft. 40 ft. Grey sand silt
5a.Well Location: 40 ft. 50 ft- Limestone shells, coarse sand
Coastal Realty 50 It. 75 ft. White Limestone
Facility/Owner Name Facility to#(if applicable) ft. ft.
Lot 2 Union Bethel Road, Hampstead, NC 28443 ft. ft.
Physical Address,City,and Zip
ft. ft.
Pender 4214-35-5668-0000 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certification:
77 37 43 295 N 34 25 28.59 w gezz, �'�� 1/06/2022
6.Is(are)the well(s)mPermanent or 13Temporary Sign re of Certified Well Contractor Date
By signing this form,I hereby certh`that the svell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ©IYes or ONo with 15A NCAC 02C.0100 or 15A NC'AC•02C.0200 Nell Construction Standards and that a
/f this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under 921 remarks section or on the hack of this,fonn.
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-I 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: 75 A) 24a. For All Wells: Submit this form within 30 days of completion of well
For nultiple wells list all depths ifdifferent(example-3 r@200'and 2@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 Infection Wells: In addition to sending the form to the address in 24a
Mud Rotary above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: 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 Supply& 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�0 completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016