GW1-2021-03070_Well Construction - GW1_20211025

w
®,
NORTH CAROLINA
ilk
WELL CONSTRUCTION RECORD (GW-1 )
EnvfronmertmfQua(Iry
Form GW-1 Well Construction Electronic Form
North Carolina Department of Environmental Quality
Division of Water Resources
April 1,2021
Submission ID#
GW1-2021-03070
Are you submitting a printed form?* Yes
No
CONTACT INFORMATION
.......................................................................................................................
Contact Name* Email Address*
Mike Hager [e-mail]
Is this a revision to the form you have previously submitted?*
Yes No
WELL CONSTRUCTION INFORMATION
........................................................................................................................................................................................................................................................................................................................................................................................................................................................
1.Who is installing these wells?*
Owner Well Contractor
1.Well Contractor Information:
Certiticate# Cert Level First Name Last Name Company Name
4261 A MICHAEL HAGER LLOYD WELL DRILLING
2.Well Construction Permit#:
NW21-014
List all applicable well construction permits(i.e.Monitoring Wells,UIC,County,CCPCUA,etc.)
What type of well is this?* Injection Well Non-Water Supply Well
Water Supply Well (includes irrigation wells)
3.Water Supply Well* Geothermal (Heating/Cooling Supply) Industrial/Commercial
Irrigation Municipal/Public/Community
Residential Water Supply(single) Residential Water Supply(shared)
Wells> 100,000 GPD
4.Date well was completed and ID#
Date Well Completed* Well ID# Well Yield
10/12/2021 (gallons per minute)"

5.Well Location
Facility/Owner Name*
Justin Scott Facility ID#
(Required) (If applicable)
County*
Pamlico
The selected county is within the Central Coastal Plain Capacity Use Area. Please reference your Capacity Use Water
Withdrawal Permit Number(CUxxxx)in Section 2.above.
Parcel Identification No.(PIN)
E06-28-3
Physical Address* Street Address
208 Mack Scott Avenue
Address Line 2
City State/Province/Region
New Bern NC
Postal/Zip Code Country
28560-5963 us
Latitude* 35.0827030000 Longitude*76.8591409000
Decimal degrees Decimal degrees
.........................................................................................................................................................................................
6.Is(are)the well(s):* Permanent Temporary
7.Is this a repair to an existing well:* Yes • 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.
For multiple Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction,only 1 GW-1 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
180 surface?
For multiple wells list all depths if different 150
(example-3@200'and 2@100') in feet
10.Static water level below top of casing: (ft.) 11.Borehole diameter:
25 8x4
If water level is above casing,use"+" in inches
12.Well construction method:
Auger Air Rotary Cable Tool
Direct Push Mud Rotary Rotosonic
Other
13. FOR WATER SUPPLY WELLS ONLY:

13a.Yield(gpm)
60 13a.Method of test:
If applicable Air Lift
13b. Disinfection type:* 13b.Amount:
Chlorine 3 oz
....................................................................
14.WATER BEARING/FRACTURE ZONES
From To Description
160 180 Limestone
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
160.00 180.00 2.00 Sch 40 PVC
in feet in feet in inches
18.GROUT
...............................
From To Material Emplacment Method&Amount
0.00 20.00 Quik Grout Pump-3 bags
in feet in feet
19. SAND/GRAVEL PACK(if applicable)
From To Material Emplacment Method
in feet in feet
20. DRILLING LOG
From To Description(color, hardness,soil/rock type,grain size,etc.)
0.00 4.00 Topsoil
in feet in feet
4.00 10.00 Blue Clay
in feet in feet
10.00 20.00 Blue clay mixed with shells
in feet in feet
20.00 30.00 Shells and blue clay
in feet in feet
30.00 70.00 Blue Clay
in feet in feet
70.00 85.00 Sandy Blue clay
in feet in feet

85.00 100.00 Sandstone/marl
in feet in feet
100.00 150.00 Sandstone
in feet in feet
150.00 160.00 Sandstone/Limestone
in feet in feet
160.00 170.00 Shellrock/Limestone
in feet in feet
170.00 180.00 Limestone
in feet in feet
21. Remarks
22.Site diagram or additional well details:
You may upload additional well construction information here.
pdf only
CERTIFICATION INFORMATION
........
* 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*
Ake 49ger
Signature of Certified Well Contractor
Submittal Date 10/25/2021