GW1-2021-00797_Well Construction - GW1_20210303

WELL
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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Justin E. Nixon 14.WATER ZONES
Well Contractor Namet., FROM TO DESCRIPTION
0 -ft- 125 ft. Sand
4265-A , , '��
NC Well Contractor Certification Number b
J ft. ft.
15.OUTER CASING for mulfi-cased wells OR LINER if a livable
Magette Well &Pump Co., Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
10272020 ,j, 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) +1 ft. 100 ft. 4.0 in. SDR-17 PVC
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public 100 ft. 120 ft. 2 in- 0.020" sch 40 PVC
_ Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial OResidential Water Supply(shared) IS.GROUT"
Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 3 ft. 77 ft. Quik-Grout Pump thru Tremie
J Monitoring ORecovery 0 ft. 3 ft. Quikrete Pour
Injection Well:
ft. ft.
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK if a livable
i Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage 77 ft. 125 ft. SP#2 Tremie
_i Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTraeer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(HeatinglCooling Return) 1 Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness,soilfrock type,grain size etc.
0 I'L 20 ft. sand with minor clay
4.Date Well(s)Completed:1-21-21 Well ID# Home Well 20 ft. 67 ft. Shells, Sand, minor clay
5a.Well Location: 67 f" 90 f`' Sand and shells
Colby Davenport 90 fc- 125 ft. Sand with minor shells
Facility/Owner Name Facility ID#(if applicable) ft. ft.
853 Meadow Lane, Creswell, NC ft. ft.
Physical Address,City,and Zip ft. ft.
Washington 21.REMARKS
County Parcel Identification No.(PIN) 10SQ07-240-3"complete unit-set 60 feet of 1.25"sure
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: align pvc drop pipe. 14/2 wire. Baker pitless adapter
(if well field,one lat/long is sufficient) 22.Cer Icati n'
35.8731399 N 76.4208911 W
1-25-21
6.Is(are)the well(s)0Permanent or Temporary Sign re of Certified WeII Contractor Date
B signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or k)No uh 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
If1his is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the ivell owner.
repair under#21 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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 120 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3@100'and 1@100') construction to the following:
10.Static water level below to of casing: 3.20
p g: (ft.) Division of Water Resources,Information Processing Unit,
tf,vater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8.75 (in.) 24b. For Iniection Wells: In addition to sending the form to the address in 24a
Mud Rotary above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 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) 30 Method of test:Airlift 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: HTH Amount: 1/2 lb completion of well construction to!the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016