GW1-2021-03178_Well Construction - GW1_20210625

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
60 ft. 80 ft.
3497-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for mulfi-cased wells OR LINER if o licable
Applied Resource Management FROM TO DIAMETER TMCKNES$ MATERIAL
ft. ft. in.
Company Name 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.UIC,County,Stale,Variance,etc.) ft. ft.
3.Well Use(check well use): fL ft.
Water Supply Well: 17.SCREEN
pp y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
J Agricultural Municipal/Public 60fL 80fL 4in• 20 PVC
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
-_;Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
0Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 60ft- Bentonite Poured
_!Monitoring DRecovery ft. ft.
-Injection-Well:' _ - _.- -- —
_j Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery .SallnitJ'Barrier FROM TO MATERIAL EMPLACEMENT METHOD
J Aquifer Test O]Stotmwater Drainage 60 ft 80 ft• #2 Sand Poured
]Experimental Technology OJ Subsidence Control ft. ft.
I Geothermal(Closed Loop) 13Tracer 20.DRILLING LOG attach additional sheets if necessary)
[]Geothermal(Heating/Cooling Return) [Other(explain under 421 Remarks) FROM TO DESCRIPTION color,hardness soil/rock type,grain siie etc.
Oft. 1 Oft• sandy top soil
4.Date Well(s)Completed: 6/8/2021 Well ID# loft. 30ft• yellow silty sand
59.Well Location: 30ft• 60ft• grey silty sand R"
Seth Ward 60ft• 80f1• limestone
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. r
421 Grants Creek ft. ft.
Physical Address,City,and Zip ft. ft. 2t10n P"-C'ssSl I. I nit
J
Onslow 531800216400 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lattlong is sufficient) 22.Certification:
34479.66N 77 17 34.28 W � IQAxe4l 06/24/2021
6.Is(are)the well(s)oPermanent or ©IJ Temporary Vii'aturc of Certified Well Contractor Date
13v signing this form,1 hereby certifv that the wells)was(were)constructed in accordance
7.-Is-this-a-repair-to-an existing well: --[3Yes_ or [3No_ with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of ihlis re-record harbreen provided-io the well owner. — ---- ------ -
repair under#21 remarks section or on the hack 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 80(ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list al/depths if dii fereni(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 15(ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617 '
11.Borehole diameter: 8 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: Mud Rotary above, also submit one cop),of this form within 30 days of completion of well
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
r
13a.Yield(gpm) Method of test: 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: 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
..l