GW1-2022-06003_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 105f`' 125f' Shells and sand
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for mulfi-cased wells OR LINER if a livable)
Applied Resource Management FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,Slate,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 Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) 105 rt• 125 ft 4 '"' 10 80 PVC
Industrial/Commercial E3Residential Water Supply(shared) 18.GROUT
Irrl ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 100 ft- Bentonite Poured
Monitoring EIRecovery 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 EMPLACEMENTMETHOD
Aquifer Test DStormwater Drainage 100 ft. 125 ft- #2 Sand PoUred
Experimental Technology OSubsidence Control ft. ft.
RGeothermal(Closed Loop) [ITracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) C1 Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soillmck type,grain size,etc.
0 ft. 15 ft- Sandy topsoil
4.Date Well(s)Completed: 11/15/2021 Well ID# 15 ft. 45 ft- Silty sand
5a.Well Location: 45 ft. 90 ft- Grey clay layerd with limestone
Terry Denny 90 ft. 125 ft. Shells and sand; u�---il
Facility/Owner Name Facility ID#(if applicable)
414 Siverside Lane, Peletier, NC ft. ft. JUN 17 2022
Physical Address,City, ft. ft.
and Zip
Carteret 5375025839410000 21.REMARKS :1c,'s7wiiv,I
County Parcel Identification No.(PIN)
1 : dVI10,J r i3OCES SIN G U1i"
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Iat/long is sufficient) 22.Certification:
7756.234N 34 43 15.905w 9&16z- ��'��y 11/15/2021
6.Is(are)the well(s):NIPermanent or OTemporary Si re of Certified Well Contractor Date
By signing this form,I hereby verb,that the ivell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: rIIYes or JDNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Nell Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nalure of the copy of this record has been provided to the well owner.
repair under#21 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-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: 125 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For unthiple wells list all depths if dierent(example-3¢200'and 2@100') construction to the following:
10.Static water level below top of casing: 18(ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 7 7/8 ln.
( ) 24b.For Iniection 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) 60 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: l-Itl-I 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