GW1-2022-05999_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 45 ft' 702tL Limestone
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 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: NA FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Countyv,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single)
56 ft. 76ft. 4 in. 20 80 PVC
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
X Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 50 ft Bentonite Poured
Monitoring EIRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage 50 ft- 76 ft- #2 Sand Poured
Experimental Technology Subsidence Control ft ft.
RGeothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 RemarksLJ FROM I TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
0 ft. 5 ft. Black Topsoil
4.Date Well(s)Completed: 12/15/2021 Well ID# 5 ft- 20 ft Yellow sand silt
5a.Well Location: 20 ft 25 It- Sand shells, quartz rock
Lou Cannon 25ft. 45 ft. Orange sand
Facility/Owner Name Facility ID#(ifapplicable) 45 ft- 76 ft White Limestone'-,e-t IF-r-j
4 Wilson Point, Trent Woods, NC 28562 ft. ft
Physical Address,City,and Zip ft. ft. `I U N 17 2022
Craven 8-053-010-A 21.REMARKS
County Parcel Identification No.(PIN) r3ti: �1Lrr�
- ?s Ji\I
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
330 4'32.76" N 770 6'18.51" W gezf' �' ,�� 12/15/2021
6.Is(are)the well(s)QPermanent or [(Temporary Signa6k 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: DYes or [RNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Nell Construction Standards and that a
/fthis is a repair,fill out Innown well construction!?formation and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back 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 I GW-1.�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: 76 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For mnhiple wells list all depths ifdifferenl(example-3@200'and 2@I00') construction to the following:
10.Static water level below top of casing: 10 (ft.) Division of Water Resources,Information Processing Unit,
Ifwaler 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.Well construction method:
Mud Rotary 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) Method of test: 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: Amount: 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