GW1-2021-04450_Well Construction - GW1_20210805

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
John Salmon 14.WATER ZONES
`
FROM TO DESCRIPTION
Weil Contractor Name
40ft• 55ft• Chunk limestone
3497-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable
Applied Resource Management FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
E H WP-550-2021 16.INNER CASING OR TUBING eotbermal closed-too
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Counry,Slate,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
Pp y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
J Agricultural OJ MunicipaUPublic 40"L 55`L 4'"' 20
I PVC
, Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft in.
_j Industrial/Commercial ©IResidential Water Supply(shared) 18.GROUT
_IlIrrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water supply Well:_ _ Oft. 40ft__Bentonite-. .P_oured-__
__,Monitoring (J Recovery ft. ft.
Injection Well:
ft. ft.
J Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EniPLACFMENT METHOD
_J Aquifer Test DStormwater Drainage 35 ft- 55ft• #2 Poured
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG lattach additional sheets if necessary)
I Geothermal(Heating/Cooling Return) )1Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soil/rock a rain size,etc.
Oft. 15ft. sand �
4.Date Well(s)Completed: 07/21/2021 Well ID# 15ft• 30 ft- silty sand clay mix
30ft• 35 ft- re silt sand
Sa.Well Location: grey Y
Jeff Caldwell 35ft• 40 ft- salt pepper sand
Facility/Owner Name Facility ID#(ifapplicable) 40ft. 50 ft. ehunk;limestone
9549 Hwy 210 Rocky Point, 28457 50ft• 55 ft' void IWO,
Physical Address,City,and Zip ft. ft.
Pender 3255-75-5091-0000 21.REMARKs
County Parcel Identification No.(PIN) 8
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Iat/long is sufficient) 22.Certification:
34 26 39 N 77 48 48 w r& 07/23/2021
6.Js(are)the well(s) s/i Permanent or �ITemporary Si a of Certified Well Contractor ', Date
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: OJ Yes or &]No with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
If this is a repair,fill out known well construction informalion and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back 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: 55(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: 8 (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 Injection 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: ry construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) f
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 48 Method of test: Air Lift 24c. For Water Supply& Injection Wells: In addition to sending the form to
o the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: I Itl I Amount: /o completion of well construction toy 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