GW1-2021-03031_Well Construction - GW1_20210622

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WELL CONSTRUCTION RECORD GW- For Internal Use Only:
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1.14'ell Contractor Information:
John Salmon n 14;WATERZONES
Well Contractor Name t FROST TO I DESCRUM0%,
c"i�tJ ul�► 60 ft. gOsr
3497-A t�
malts-casedContractorni r ft. fa
tS:OUTERCASING for
NC tVelt Contractor Ccfication Number 1nlloor,�D
3,U eW OR LINER If a Ilnbk
Applied Resource Management FRONT s TO DIAMfETER In TtI1CTCA FSS MTERIAL
Company Name 16.INNER CASING ORTUBING ermsl closed
2.Well Construction Permit it: 2020074852 FRONT To DIAMILTER THICKwss 31.17 EntAL
list all applirehle%vil con-aructbrn permits to a 111C.County,Stale,l'a Mare,era) ft. ft. In.
3.Well Use(check well use): fL iL in.
,.17I SCREEN.
Water Supply Well: FROST I To I DIAMETER SLUT S17.6 I THICKNESS I MIATERIAL
Agricultural [3Niuncipalftblic 64iL 80tL 4hr. 20
Geothermal(Hcating/Cooling Supply) Residential Water Supply(single) p rt. is
Industrial/CommcrcialResidential Water Supply(shared) I&GROUT
:jlffiLmtjon Most TO MATERIAL: 1tPLAC S1F-SirMtI IOD&AMtOUNr
_
Non-Water Supply well: 0 R. 55 n• Bentonit F:
e _ Tre_mmie
Monitoring ❑Recovery ft. R.
Injection Well:
fL i4
Aquifer Recharge []Groundwater Remcdtation
(19 SANDIGRA4rEL PACK ifa cable
Aquifer Storage and Recovery [3Salmity Barrier FRONT To SIATERIAL LMPucEttENT MII:TIIOD
AquifcrTcst ❑StormwutcrDrainage Soft. 80tL #2 Pour
Experimental Technology 0Subsidcnce Control fit. fl.
Geothermal(Closed Loop) [3Trocer 20:DRILLING LOG attach■aruflonaleheeta Ifmmoa
Geothermal(F)eatin Cootie Return) Other(ex lain under 421 Rcmurks) "'TO
'T To DESCRIPT1a1Y color hardn ns.aoll/rock a dsr.etc.
0fL 10• black and white silty sand
4.Date Well(s)Completed: 06/03/2021 well lDo lot,. 20 fit• grey sand
5a.WL-11 Location: 20fl- 30 ft.. grey sand fine sand
Shawnta Smith 30 ft- 40 ft. layered grey sand shells small gravel quarts
Facibty/Owner Name Facility IDN(irapplicable) 40 ft. 80 f' Way sand,pee sized whae and dear quart and sit
9139 Green Loop Rd. Leland, NC 28451
Physical o%ddreu,City,and Zip ft. IT.
Brunswick 0160005102 21.REMARKS
County Parcel Identification No.(PINT
5b.Latitude and longitude in degreeslminutestseconds or decimal degrees:
(if%veil field,am lot/long is sufficient) 22.Certification:
34 78 10.75N 78 04 15.3711
6.Ts(are)the wcll(s)J3Permanent or [Temporary Si t cn ficd Well Conuactor Dale
Mr signuW this jrrm„I hereby cerlifi,that the r,•ellis).aas(m ere).comtrtated in.accartlance .
7.Is this a repair to an existing well- 01'es or ONO with 1JA NCrlf'0:C',0100 or 1.54 ht:aC 62(7.f1200 Melt Camtruction landards and that a
If this 1s a repair,fill out komtrr,well cansrrurnan information and explain the mature of rite ctsin,e f This mcnrd has heen pnn•lded ro the,cell owner
repair under n 2 1 remmrks Median nr on the hack of this jrm.
23.Site diagram or additional well details:
II.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-1 is needed. Indlcale'rOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled' StillN1P1-PAI,iNSTRII-CTIONS
9.Total well depth below land surface: 80 Ut•) 24a, For All Wells- Submit this form within 30 days of completion of well
For muhiple+Tells list all depths tfdierent(uumple.PLt,•_00'anl2 r�"q.l trf!') construction to the foliowmg
10.Static water level helow top of casing: 35 ift.) Division of Water Resources,information Processing Unit,
ifwaterlcrrl is above caring,use 1617 Mail Service Center,Ralelgh,.NC 27699-1617
11.Borehole diameter: 7 7/8 (in.) 24b. For Injection Wells: In additton 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: Rotary construction to the following-
(i.e auger,rotary,cable,direct push,cie.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 10 Method ortest: Air Lift 24c.For Water Sonnh'& infection Wells: In addition to sending the form to
D the addrtss(cs) above, also submit one copy of this form within 30 days of
13b.Disinfection IN pe: HTH Amount: 3/o at 1 0g completion of well construction to the county health department of the county
where constructed.
Form GW-1 Nonh Carolina Department of Environmental Quality-Division of Wmcr Resources Revised 2-22-2016