GW1-2022-06917_Well Construction - GW1_20220722

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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
ft. ft.
3497- A
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
Applied Resource Management FROM TO DIAMETER THICKNESS MATERIAL
ft, ft. I in.
Company Name
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. UC,County,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
PIAgricultural [3Municipal/Public ft, ft, in.
®Geothermal(Heating/Cooling Supply) [3IResidential Water Supply(single) ft R, in.
PIIndustrial/Commercial [3IResidential Water Supply(shared) 18.GROUT
ipIrrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
Monitoring Recovery
Injection Well:
LJft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
®IAquifer Storage and Recovery Dl Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 01 Stormwater Drainage
Experimental Technology [:]I Subsidence Control
bGeothermal(Closed Loop) [:IITraeer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) FROM TO DESCRIPTION(color,hardness,wil/rock e,grain size,etc.[:]I Other(explain under#21 Remarks) 0 ft. 10 ft.
Sand
4.Date Well(s)Completed: 05/10/2022 Well ID# 10 ft. 30 ft' Grey silty sand
5a.Well Location: 30 ft' 35 ft' Limestone shell mix
John Pernell 35 ff 108 ft' Limestone
Facility/Owner Name Facility ID#(ifapplicable) 108 ft' 210 ft' Grey sand
528 E Front Street, New Bern 28560 210 ft. 300 ft. Sand grey limestone
Physical Address,City,and Zip ft. ft. Mix with clay
Craven 8-003-260 2L REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
77 37 35 55 N 34 24 41 704 W Q,g"01 05/10/2022
6.Is(are)the well(s):®IPermanent or [3ITemporary Vine of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3IYes or ®No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature of the copy ofthis record has been provided to the well owner.
repair under 421 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: 300 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3CJ)200'and 2@100') construction to the following:
10.Static water level below top of casing: 10 (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: 5 7/8 m.
( ) 24b. For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method Mud Rotary above, also submit one copy of this form within 30 days of completion of well
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) 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-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016