GW1-2022-07913_Well Construction - GW1_20220823

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information:
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DAVID HALL 14.WATER ZONES l i
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
A - 4459 ft. ft.
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. P +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.U1C,County,State,Variance,etc) 0.0 fr• 6.0 ft. 2.0 In. SCH 40 PVC
3.Well Use(check well use): R. tt. in.
17.SCREEN
Water Supply Well:
ppy FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 6.0 ft' 16.0 ft' 2.0 in.
.010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) R. rt. in'.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl atlon ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 3.0 ft' PORTLAND.8ENTONUE SLURRY
OMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PAC K(ifapplicable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO I MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 4.0 ft. 16.0 ft. 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#21 Remarks) FROM To DESCRIPTION color,hardness,soil/rock type, Mj2 size,etc.
0.0 rt• 16.0 rt• SILTY SAND
4.Date Well(s)Completed: 08/02/22 well ID# FOR-MW-1
ft. ft.
5a.Well Location:
HARVEY POINT FEDERAL FACILITY
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:
(ifwell field,one laulong is sufficient) 22.Certification:
360 05' 47.22" N 760 19' 36.23" w 08/16/22
6.Is(are)the well(s): (91'ermanent or ❑Temporary Signature ofCertified Well Contractor �%ate E a I E...
By signing ihis farm,1 hereby cert fy that the uvll(s)u•as(were)cons•trucled in accordance with
7.Is this a repair to an existingwell: ❑Yes or ONo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well C'onsvruc•tio t arts-d I-�/, 2 tpy
I/this is a repair,fill out known well constructioninJorniation and explain the nature of the of this record has been provided to the well owner. ��J� .: L V L�
repair under 921 remarks section or on the back of this form.
23.Site diagram or additional well details: i• rt �r4�f6rE7i URi1��,,,,�� t' 91i4.i•'
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additi nal w t" g III o
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach addition pages If necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 16.0 (ft.)
hor multiple wells list all depths Y'dif/erenl(example-3 rt 200'and 2 a@100') Submit this GW-I within 30 days of well completion per the following:
6.0 24a. For All Wells: Original forin to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit, 1617'MSC,Raleigh,NC 27699-1617
If water level is above casing,use"i
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11.Borehole diameter: 8.0 (in.) 24b. For Injection Wells:Copy to DWR,Underground Injection Control (IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(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 producinjPover 100,000 GPD: Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
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13b.Disinfection type: Amount:
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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