GW1-2021-05318_Well Construction - GW1_20211001

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
John Salmon 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3497-A 45ft 55ft• fine sand
ft. ft.
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NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
Applied Resource Management FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-too
2.Well Construction Permit tt: 2014071 779 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Coimn y,Slate, Variance,etc.) ft• ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ®Municipal/Public 45fL 55fL 4in• 10 sch 60 PVC
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft.
_]Industrial/Commercial Residential Water Supply(shared) 18.GROUT
_.Irrigation FROM TO MATERIAL E1%1PLACEMENT METHOD&AMOUNT
Non-Water Supply well: 0 ft. 45 ft- Bentonite Poured
Monitoring �Recovery ft ft
Injection Well:_1 Aquifer Recharge OGroundwater Remediation ft. R.
19.SAND/GRAVEL PACK if a licable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
J Aquifer Test []Stormwater Drainage 45 ft- 55 ft. #2 Sand Poured
Experimental Technology Subsidence Control ft. ft.
J Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
J Geothermal(Heating/Cooling Return) -_ Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness soil/rock t3Te,gmin size,etc.
0 ft 10 ft- top soil and sand
4.Date Well(s)Completed: 09/16/2021 Well ID# 10fL 45ft. clay sand mix
5a.Well Location: 45 ft- . 55ft• fine sand clay lenses
Kathy Benton 55" 57ft• hard pack clay
Facility/Owner Name Facility ID#(if applicable) ft. ft.
RtUtIVED
1359 Ross Cole Tr. Leland, 28451 ft. ft.
Physical Address,City,and Zip ft. ft. If1
Brunswick 056JA001 21.REMARKS WOF19218tioll Pro ssmg Unit
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
78 7.43 888 N 34 11.4 574 w zzl I�YaAtlelpwl 09/16/2021
6.Is(are)the well(s)oPermanent or OTemporary Si tore of Certified Well Contractor Date
-' 'Hvstgning thisjorm,-I hereby certfv lhatrthe well(s)was(were)_constructed in accordance
7.Is this a repair to an existing well: Yes or �No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and Thal a
If this is a repair,fill out known well construction information 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTION'S
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 dierent(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,
t(water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 7 7/8(in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
Mud Rotary above, also submit one copy of this'form within 30 days of completion of well
12.Well construction method:(i.e.auger,rotary,cable,direct push construction to the following:,etc.) ,
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) 20 Method of test: Air Lift 24c. For Water Sunvly& 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: HtH Amount: 20 o�0 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