WI0800524_Report_20191209

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WELL CONSTRUCTION RECORD (GW-11
1. "'ell Contractor Information: -- - - "
John Salmon
Well Contractor Name
3497-A
NC Well Contractor Cenification N'mnber
Applied Resource Managemeotj-1 r31!ons`
Company Name W10800524
2. Well Construction Permit p:
List all appluvrhk well cons/..¢lion r mars /i.v. 17(Cmato', State. ion ..ce, etc)
3. Well Use (check well use):
(Heating/Cooling Supply')
Recharge
Storage and Recovery
Test
rental Technology
mal (Closed Loop)
Municipal/Public
❑Residential Water Supply (single)
Residential Water Supply (shared)
Groundwater Remediation
Salinity Barrier
® Stormtlater Drainage
®Subsidence Control
❑Tracer
4. Date Well(s) Completed: l l/14/2019 Wen Ing N/A
St. Well Location:
Mark Waslo
N/A
Facility/Owner Name Facility IDd (if applicable)
4439 Midshipman Court SE, St James NC 28461
Physical Address. City, and Zip
Brunswick 206614446951
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees
For Internal Use Only:
14. WATERZONES
FROM
TO
DESCRIPTION
ft.
ft.
15. OUTER CASING for multi-casedwells OR LINER ifa Gcable
TO DIAMETER
THICKNESS IIMI4IL
0 fL 300 ft. 1 1 in
HDPE
16. INNER CASING OR TUBING eothermal
closed -too
FROM TO DLAMETER
THICKNESS
MATERIAL
ft. ft. in.
R• - ft. in,
17. SCREEN
FROM TO
DIAMETER
SLOTSIZE
THICKNESS
MATERIAL
R. I ft.
in.
ft. ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 IL
300 f'•
Thermex
Pumped
ft.
ft.
ft.
H.
19. SAND/GRAVEL
PACK
ifs Iipble
FROM
TO
MATERIAL
LA EMPCEMENT METHOD
ft.
ft.
fa
ft.
20. DRILLING
LOG atach
additional sheets ifnecsssa
FROM
TO
DESCRIPTION holaq hardness, soit/mck ty,e. grain she, etc.
0 fL
25 f'•
Sandy clay to clay
25 f'•
180 f'
Limestone
180 ft.
210 0*
MCEIVEDMCDENRItfik
Limestone clav mix
210 f'•
300 f'•
Clay
ft.
ft.
JAN 2 4 2020
ft.
ft.
ft.
ft.
Water Quality ReWo
2L REMARKS era tons zte
Wilmington Re.Riona
(if well field, one lat/long is sufficient) 22. Certifiea '6I :
See attached N See attached W �1J /,
11 /14/2019
6. Is(are) the well(s)ox Permanent or E3Temporary gnature fce dI el Contractor Date
By signing this form, I herehi certh, that the u'ellrs) u'es (were) co..ln ved in accordance
7. Is this a repair to an existing well: ®Yes or Ex No u'hh IJA NC'AC 02C.0100 or 15A NCAC 02C.0200 Nell Construction Standards and thin a
/f this is a repair, fill out known well coustnnction in formation and erplain the nave of the copy of this record has beenpmt ided to the well ou ner.
repair under =21 renmrks section or on the hack of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 5
9. Total well depth below land surface: 300 (ft )
For undliple welt list all depths if di ferem (example- 3a200' and 2@100')
10. Static wafer level below top of casing: NIA (ft.)
If water level is ..bore casing, pre , - ,
11. Borehole diameter: 6 (in.)
12. Well construction method: Mud Rotary
(ic. auger, rotar)', cable, direct push, etc.)
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
constmction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
249. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
WR
lal
fFice
Division of Water Resources, Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center, Raleigh, NC 27699-1636
13a. Yield (gpm) N/A Method of test: N/A 24c. For Water Suunh• & Infection 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: N/A Amount: NSA completion of well construction to the county health department of the county
where constmcted.
Form G W-1 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

ARM Project Number: 4439 Midshipman Ct SE Pagel
Driller:
John Salmon
Date Drilled:
Loop No.
Loop Depth
GPS
Coordinates
10/30/2019
1
300
33 55312517
78 7392587
11/4/2019
2
300
33 55313074
78 7405496
11 /5/2019
3
300
33 55318013
78 7394636
11/12/2019
4
300
33 55316514
78 7392792
11/14/2019
5
300
33 55323424
78 7396835
RECEIVEDINCDENRIDWR
JAN 2 4 2020
Water Quality Reg!onal
pperations Sectioal �ce
Wilmington Reg'