GW1-2021-00348_Well Construction - GW1_20210127

Print Form
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
John Salmon 14 WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
3497 - A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for malti-cased wells OR LINER if a licable
ft.
Applied Resource Management FROM TO ft. DIAMETER in. TRICKNESS MATERIAL
Company Name ..
E H WP'00318-2020 16.INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit 4: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Stale, Variance,etc.) f. 45 ft. 4 1°' .SCiH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
J Agricultural []Municipal/Public 0 45 fL 65 fL 4 in- .010 Sch 40 PVC
�J Geothermal(Heating/Cooling Supply) E;Residential Water Supply(single) ft. ft. in.
J Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
_.Irrl ation FROM TO MATERIAL_ EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 25 ft. Bentonite POUT
D Monitoring ❑Recovery 35 ft. 40 ft. Bentoriite POUT
Injection_W.-ell: --
ft. ft.
—,Aquifer Recharge DGroundwater Remediation
'119.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
3 Aquifer Test OStormwater Drainage 40 rt. 65 ft- #2 Pour
Experimental Technology Subsidence Control ft. ft.
3Geothermal(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,soillrock 'ain size,etc.
0 ft. 11 ft. sand to sandy clay
4.Date Well(s)Completed: 1/06/2021 Well ID# 11 ft. 25 ft. limestone
5a.Well Location: 25 ft. 65 ft. coarse sand&limestone layers
Michael Willman ft. I
ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
102 Reynolds Dr. Rocky Point, NC 28457 ft. ft.
Physical Address,City,and Zip ft. ft.
Pender 3223-45-4444 2L REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
34 23 31.62 N 77 54 32.01 W _ c�G:LL1�2erL 01/21/2021
6.Is(are)the well(s):aPermanent or ❑Temporary^ k,T;��, .r �Signah of Certified Well Contractor Date
t By signing this form,I hereby cerlifv that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well:- [IYes._or __ with 15A N_CAC_02C.0I00 or 15A NCAC 02C 0200_:Well-Consiruction.Smndards and that-a--——
If this is a repair,fill out known well construction information and explain1l e r1,1 glhe1ZJ �cpy of this record has been provided to the'well owner.
repair under tit/remarks section or on the back of this form. J ,23.Srteediagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells•having'lie:same t'.,."You may use the back of this page to provide additional well site details or well
"construction details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER o
drilled:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 65 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 3 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8 (in.) 24b. For Infection Wells: In addition to sending the form to the address in 24a
Mud Rota above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: r 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) Method of test: 24c.For Water Sunnly& 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: Amount: 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