GW1-2022-07914_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 4
Well Contractor Name FROM TO DESCRIPTION
A - 4459 ft. rr. 1
ft. ft. 1 l
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. I ft. in.
Company Name i
16.INNER CASING OR TUBING 'eothermal closed-low
2.Well Construction Permit#• FROM TO DIAMETER THICKNESS MATERIAL
Li,cl all applicable well construction permits(i.e.U/C,County,State,Variance,etc.) 0.0 ft. 6.0 ft. 2.0 in' SCH 40 PVC
3.Well Use(check well use): fr. tr. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public C.0 rt. 16.0 ft' 2.0 1°' .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 3.0 ft. PORTLANDSENTONITE SLURRY
25Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 4.0 ft 16.0 ir' 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. I 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,gmin size,etc.
0.0 rr 5.0 fr CLAY
4.Date Well(s)Completed: 08/03/22 well ID# ASP-MW-2 S.0 f- 16.0 tr. SILTY CLAY
ft. ft.
5a.Well Location:
HARVEY POINT FEDERAL FACILITY rt. fr.
Facility/Owner Name Facility ID#(ifapplicable) ft. fr.
2835 HARVEY POINT ROAD HERTFORD 27944
Physical Address,City,and Zip
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 hit/long is sufficient) 22.Certification:
360 05' 47.22" N 760 19' 36.23" W
08/16/22
6.Is(are)the well(s): TPermanent or ❑Temporary Signature of Certified Well Contractor Date Hy signing this form,/hereby c•erti.y that the well(s)was(wer w�u ed't acc�a%Jc (ID
7.Is this a repair to an existing well: ❑Yes or [TNo 15A NCAC 02C.0100 or 15A NCAC OIC.0200 Well Construction Standards and that a copy
l/'this is a repair,(ill out known well construction information and explain the nature of the ol'this record has been provided to the ii'ell owner. /� I r+ ^0^2
repair under- ie A(J 2l remarks section or on the back gI'dis br r � � Ll)L
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 ad It' r l cpgzpf! jjl#9 Urra
construction,only I GW-1 is needed. Indicate TOTAL NUMBER ofwells (add'See Over'in Remarks Box).You may also aria t lon�, LfOGssary.
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 16.0 (ft.)
bor multiple ire/As list all depths i.di&renl(example-3@200'and 1@100') Submit this CW-1 within 30 days of well completion per the following:
6.0 24a. For All Wells: Original toim to Division of Water Resources (DWR),
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1n er level is above casing,use"+Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
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11.Borehole diameter: 8.0 (in.) 24b. For Injection Wells: Copy tb DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER i,
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
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing`Aver 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: Permit Program, 1611 MSC,Raleigh,NC 27699-161 1
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