GW1-2021-00117_Well Construction - GW1_20210609

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WELL CONSTRUCTION RE •RD ,
NORTH CAROLINA
EnWronmental Quullty
•rm GW-1 Well Construdon Electronic •
North Carolina Department of En\Aronmental Quality
April 1,2021
Page 1
Submission ID#
GW 1-2021-00117
CONTACT INFORMATION
..................................................................................................................................... .....................................................................
Contact Name* Email Address*
Mike Hager [e-mail]
Is this a revision to the form you have previously submitted?
f Yes r No
WELL CONSTRUCTION INFORMATION
.........................................................................................................................................................................................
1.Who is installing these wells?*
r Owner r Well Contractor
1.Well Contractor Information:
.............................................................................................................................................................................................
Certiticate# Cert Level First Name Last Name Company Name
4261 A MICHAEL HAGER LLOYD WELL DRILLING
2.Well Construction Permit#:
List all applicable well construction permits(i.e.Monitoring Wells,UIC,County,CCPCUA etc.)
What type of well is this?* r Injection Well r Non-Water Supply Well
r Water Supply Well(includes irrigation wells)
3.Water Supply Well* r Geothermal(Heating/Cooling Supply) r Industrial/Commercial
r Irrigation r Municipal/Public/Community
r Residential Water Supply(single) r Residential Water Supply(shared)
r Wells>100,000 GPD
4. Date well was completed and ID#
Date Well Completed* Well ID# Well Yield
6/9/2021 50
(gallons per minute)"

Page 2
5.Well Location
Facility/Owne r Name*
Mark Johnson Facility ID#
(Required) (If applicable)
County*
Pamlico
The selected county is within the Central Coastal Plain Capacity Use Area. Please reference your Capacity Use Water
Withdrawal Permit Number(CLlxxxx)in Section 2.above.
Parcel Identification No.(PIN)
Physical Address* Street Address
601 Raymond Road
Address Line 2
City State/Province/Region
Arapahoe NC
Postal/Zp Code Country
28510-9626 US
Latitude* 34.9829640000 Longitude*76.8372517000
Decimal degrees Decimal degrees
6. Is(are)the well(s):* r Permanent r Temporary
7. Is this a repair to an existing well:* r Yes r No
If this is a repair,fill out known well construction information and a)plain the nature of the
repair under#21 remarks section or on the back of this form.
For multiple Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction,only 1 GW-1 is needed.
8a. Indicate TOTAL NUMBER of wells drilled: 1
9.Total well depth below land surface:(ft.) 9a.What is the depth of the casing from ground
220 surface?
Formultiplewells Iistall depths if different 190
(example-3@200'and 2@100') in feet
10.Static water level below top of casing:(ft.) 11. Borehole diameter:
29 8x4
If water level is above casing,use"+" in inches
12.Well construction method:
r Auger r Air Rotary r Cable Tool
r Direct Push 6- Mud Rotary r Rotosonic
r Other
13. FOR WATER SUPPLY WELLS ONLY:

13a.Yield (gpm)
50 13a. Method of test:
If applicable Air Lift
13b. Disinfection type:* 13b.Amount:*
Chlorine 3 oz

Page 3
14.WATER BEARING/FRACTURE ZONES
From To Description
190 LZU Limestone
in feet in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
From To Diameter Thickness Material
in feet in feet in inches
17.SCREEN
From To Diameter Thickness Material
190.00 220.00 2.00
in feet in feet in inches
18.GROUT
From To Material Emplacment Method &Amount
0.00 20.00 Quik Grout Pump
in feet in feet
19.SAND/GRAVEL PACK(if applicable)
From To Material Emplacment Method
in feet in feet
20.DRILLING LOG
From To Description (color, hardness, soil/rock type, grain size,etc.)
0.00 20.00 Sandy Red Clay
in feet in feet
20.00 40.00 Sand/shells/blue clay
in feet in feet
40.00 147.00 Blue Clay
in feet in feet
147.00 170.00 Sandstone w/streaks of limestone
in feet in feet
170.00 190.00 Shellrock
in feet in feet
190.00 220.00 Limestone
in feet in feet
21.Remarks
22.Site diagram or additional well details:

You mayupload additional well construction information here.
pdf only
*rJ By signing this form, I hereby certify that the well(s)was(were)constructed in accordance with 15A NCAC 02C
.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy of this record has been provided to
the well owner.
23.Certification*
Ake old -
Signature of Certified Well Contractor
Submittal Date 6/9/2021