GW1-2022-07912_Well Construction - GW1_20220823

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID HALL 14.WATER ZONES f 1
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
A - 4459 rt. I fr. I
t
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U/C,County,State,Variance,etc) 0.0 ft. 6.0 if 2.0 in. SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 6.0 ft' 16.0 fr. 2.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in•
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl atlon ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 3.0 ft' PORTLANDBENTONITE SLURRY
OMonitoring ORecovery ft. fr.
Injection Well:
tr. fr.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK ifa licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 4.0 ft- 16.0 it. 20-40 FINE SILICA SAND
❑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 421 Remarks) FROM TO DESCRIPTION color,hardness,soiUrock type,grain size,etc.
0.0 ft. 16.0 ft- SILTY SAND
4.Date Well(s)Completed: 08/01/22 Well ID# SDS-MW-1 R ft. ft.
ft. ft.
5a.Well Location:
HARVEY POINT FEDERAL FACILITY ft. fr.
Facility/Owner Name Facility ID#(ifapplicable) ft, ft.
2835 HARVEY POINT ROAD HERTFORD 27944 ft. ft.
Physical Address,City,and Zip ft. ft.
PERQUIMANS 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL 3.0 4.0 FEET-
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) 22.Certification:
360 05' 47.22" N 760 19' 36.23" W �
08/16/22
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
by signing this/brm,I hereby certify ihol the well(.$)ryas cled c r��"�n
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or I5A NCAC 02C'.0200 Well Cons uj"' a Rd I�ar�r
4 this is a repair,fill out known well construction tlrfbrmalion and explain the nature of*1he of this record has been provided to the reel/owner. 1 ^
repair under�21 remarks section or on the back of lhi.s form. AUG r ) 2022
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 constructio0 inf
ng
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also adia86a}�3aSe-s4fen�.
drilled: Dill QhB G
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 16.0 (ft.)
Vor multiple wet/s list all depths ijdifJerem(example-3@200'and 2 rd100') Submit this GW-1 within 30 days of well completion per the following:
6.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit, 1617,MSC,Raleigh,NC 27699-1617
/ju•nler level is above casing,use"{"
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11.Borehole diameter: 8.0 (in.) 24b. For Injection Wells:Copy 10 DWR, Underground Injection Control (IUC)
Program, 1636 MSC,Raleigh,NCj27699-1636
12.Well construction method: AUGER
24c.For Water Supply and Open-Loon Geothermal Return Wells:Copy to tine
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells Water WeIIs producingover 100,000 GPD]00,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh;NC 27699-1611
13b.Disinfection type: Amount:
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Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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