GW1-2021-05350_Well Construction - GW1_20211013

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Charles N Dozier , 14.WATER ZONES,
Well Contractor Name b�lur` �Otl FROM I TO I DESCRIPTION
4088-A C j 1 00 1" 20 ft- 80 ft.
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased:wells OR LINER if a licable
Toano Well and Pump Service Inr ��ct^�,����Qc FROM To DIAMETER THICKNESS MATERLIL
�• n ft. ft. in.
Company Name 16.INNER CASING OR TUBING(geather at closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) +2.5 lt- 20 ft- 4 in. SDR17 pvc
3.Well Use(check well use): ft. ft. in.
[Nn
Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ultural ®Municipal/Public 20 ft- 30 ft. 4 inl 0.020 PVC
ermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
trial/Commercial Residential Water Supply(shared)
iS.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ater Supply Well: 15 ft. 0 ft. Hole Plug Pw fr top seaung pipe and p�g.emuewM
itoring Recovery
on Well:fer Recharge ®Groundwater Remediation19.SAND/GRAVEL PACK tf a licablefer Storage and Recovery [3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
fer Test [3Stormwater Drainage 30 ft. 15 fL #3 Silica sand Tremmie
rimental Technology Subsidence Controlhermal(Closed Loop) Tracer -20.DRILLING LOG attach additional_sbeets if necessahermal(IIeatin Cooling Retum Other ex lain under#21 Remarks FROM To DESCRIPTION color,hardness,soillrock in size,etc.
0 ft. 10 ft. Orange Sand
4.Date Well(s)Completed:06/25/2021 Well ID#G 15E3 10 ft. 30 ft. Blue Clay with sand and shell
5a.Well Location: ft. ft.
NCDENR ft. ft.
Facility/Owner Name Facility m#(if applicable)
rt. ft.
125 SANDY RIDGE ROAD, EDENTON, NC 27932 ft. ft.
Physical Address,City,and Zip ft. ft.
Chowan .11.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
36.1653162 N -76.6502900 W
- 07/14/2021
6.Is(are)the well(s)oPermanent or Temporary Signature of Certified well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or ONo with 15A NCAC 02C.0100 or ISA NCAC 01C.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#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-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: 30 (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: 3 (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: 10 (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: 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
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