GW1-2021-03896_Well Construction - GW1_20210823

.Print Form
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Onlv:
1.Well Contractor Information: 7
Sanford Sweeting 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
2082-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 1NICKNBSS 11IATERIAL
ft. ft. in.
Company Name
EHWP-0O585-2021 16.INNER CASING ORTUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construclion permits(i.e. UIC,County,State,Variance,etc.) 105ft. +1 ft. 4 in. Sch 40 PVC.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public 135fL 115ft- 4in. .020 Sch 40 PVC
Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.J
3 Industrial/Commercial [✓i Residential Water Supply(shared) 18.GROUT
1 Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 105ft• 0.0 ft- Bentonite Pour
_i Monitoring ORecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge DGroundwater Remediation 19.SAND/GRAVEL PACK if applicable)
[;Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD Ci
J Aquifer Test DStormwater Drainage 135ft• 105 ft, #2 Pour
J Experimental Technology DSubsidence Control ft. ft.
EGeothermal
Geothermal(Closed Loop) DTracer 20.DRILLING LOG attach additional sheets if necessa(Heating/Cooling Return) _I Other(explain under 421 Remarks) FROM TO DESCRIPTION color,hardnes soil/rock type,Wmin size,etc.
Oft• 30ft• sandy stone silt
4.Date Well(s)Completed: 08/16/2021 Well ID# 30ft• 70fL sandy clay
70ft• 105ft- silt sands .�
5a.Well Location: y
Harry Cordts 105ft• 135ft- limestone
Facility/Owner Name Facility ID#(if applicable) ft. ft. �ysy
67 Shark Landing Hampstead 28443 ft. ft. -
Physical Address,City, p ft. ft. `` J ^ t
Y t}',and Zip v'' :�:'.•=)
Pender 4236-70-3138-0000 21.REMARKS
p..Yts
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iatilong is sufficient) 22.Certification:
34 27 22.309 Nr 77 32 57.537w 1 lrl&a 08/16/2021
6.Is(are)the well(s)oIJ Permanent or OTemporary Signature 6PCertified Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or '✓J No with 15A NCAC 02C.0100 or 15A ATCAC 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 this record has been provided to the well owner,
repair under 921 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-I 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: 135(ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiereni(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 10 (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
Mud Rotary above, also submit one cop),of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division ofwater Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 60 GPM Method of test: Air Lift 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: HtH Amount: �b 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