GW1-2021-00210_Well Construction - GW1_20210624

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WELL CONSTRUCTION RE •RD ,
NORTH CAROLINA
EnWronmental Quullty
•rm GW-1 Well Constructon Electronic •
North Carolina Department of En\Aronmental Quality
April 1,2021
Page 1
Submission ID#
GW 1-2021-00210
CONTACT INFORMATION
..................................................................................................................................... ...............................................................................................................................
Contact Name* Email Address*
Alyce Bean [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
3497 A JOHN SALMON, III APPLIED RESOURCE MANAGEMENT
2.Well Construction Permit#:
List all applicable well construction permits(i.e.Kibnitoring 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
6/24/2021 30
(gallons per minute)"

Page 2
5.Well Location
Facility/Owne r Name*
Jon Lewis Facility ID#
(Required) (If applicable)
County* Parcel Identification No.(PIN)
Pender 4202-16-2810-0000
Physical Address* Street Address
337 olde point loop
Address Line 2
257
City State/Province/Region
Hampstead NC
Postal/ZZp Code Country
28443 United States
Latitude* -34.3660470000 Longitude lf7.6707030000
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 F No
If this is a repair,fill out known well construction information and e)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 GWA is needed.
8a. Indicate TOTAL NUMBER of wells drilled:
9.Total well depth below land surface:(ft.) 9a.What is the depth of the casing from ground
100 surface?
For multiple wells listall depths if different 88, 100
(example-3 a200'and 2@100') in feet
10.Static water level below top of casing:(ft.) 11. Borehole diameter:
25 8
If water level is above casing,use"+" in inches
12.Well construction method:
r Auger r Air Rotary r Cable Tool
r Direct Push r Mud Rotary r Rotosonic
r Other
13. FOR WATER SUPPLY WELLS ONLY:
13a.Yield(gpm) 13a. Method of test:
If applicable
13b. Disinfection type:* 13b.Amount:*
HTH 11b

Page 3
14.WATER BEARING/FRACTURE ZONES
From To Description
VV
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
100.00 4.00
in feet in feet in inches
18.GROUT
From To Material Emplacment Method &Amount
0.00 80.00 bentonite poured
in feet in feet
19.SAND/GRAVEL PACK(if applicable)
From To Material Emplacment Method
80.00 100.00 #2 sand Poured
in feet in feet
20.DRILLING LOG
From To Description (color, hardness, soil/rock type, grain size,etc.)
0.00 20.00
in feet in feet
20.00 40.00 grey silty sand
in feet in feet
40.00 60.00 clay sand shell mix
in feet in feet
60.00 100.00 limestone
in feet in feet
21.Remarks
22.Site diagram or additional well details:
You mayupload additional well construction information here.
WCR.pdf 1.34MB
pdf only

*W 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*
a5�11/lwlw'
Signature of Certified Well Contractor
Submittal Date 6/24/2021

Print Form
WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
John Salmon
Well Contractor Name
3497-A
NC Well Contractor Certification Number
Applied Resource Management
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
pAgricultural
BGeothermal (Heating/Cooling Supply)
Industrial/Commercial
®I Irrigation
Non -Water Supply Well:
Monitoring
Injection Well:
Aquifer Recharge
tiAquifer Storage and Recovery
BAquifer Test
Experimental Technology
bGeothermal(Closed Loop)
0IGeothermal (Heating/Cooling Return)
ID Municipal/Pub lic
10 Residential Water Supply (single)
10 Residential Water Supply (shared)
EIRecovery
ElGroundwater Remediation
Salinity Barrier
Stormwater Drainage
ElSubsidence Control
ElTracer
DOther (explain under #21 Remarks)
4. Date Well(s) Completed: 06/24/2021 Well ID#
5a. Well Location:
John Lewis
Facility/Owner Name
Facility ID# (if applicable)
337 Olde Point Loop Hampsead 28443
Physical Address, City, and Zip
Pender 4202-16-2810-0000
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field, one lat/long is sufficient)
34 21 57.77 N 77 40 14.53 W
6.Is(are)the well(s):0]Permanent or Q]Temporary
7. Is this a repair to an existing well: DIYes or ®No
If this is a repair, fill out known well construction information and explain the nature of the
repair under #21 remarks section or on the back 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:
9. Total well depth below land surface:
For multiple wells list all depths if different (example- 3(a,200' and 2@ 100')
100 (ft.)
10. Static water level below top of casing: 25 (ft.)
If water level is above casing, use "-
11. Borehole diameter:
8 (in.)
12. Well construction method: Mud Rotary
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
For Internal Use Only:
14. WATER ZONES
FROM
TO
DESCRIPTION
80ft•
100ft•
20 Slot 4"
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if ap licable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
88 ft.
100 ft•
4 in.
20
4"
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft.
80 ft*
Bentonite
Poured
ft.
ft.
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
go ft.
100ft*
#2 Sand
Poured
ft.
ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soillrock type, grain size, etc.)
0 ft.
20 ft.
Sand
20 ft.
40 ft.
Grey silty sand
40ft•
60 ft.
Clay sand shell mix
60 ft.
100 ft.
Limestone
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
22. Certification:
/uv Salmav
SieY%fture of Certified Well Contractor
06/24/2021
Date
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. Site diagram or additional well details:
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.
SUBMITTAL INSTRUCTIONS
24a. 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:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Form GW-1
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016