GW1-2021-05962_Well Construction - GW1_20211202

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NORTH CAROLINA
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WELL CONSTRUCTION RECORD (GW-1 )
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Form GW-1 Well Construction Electronic Form
North Carolina Department of Environmental Quality
Division of Water Resources
November1
Submission ID#
G W 1-2021-05962
Are you submitting a scanned form?* Yes
No
CONTACT INFORMATION
.......................................................................................................................
Contact Name* Email Address*
Matt 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
4160 A JOHN SWITZER TRADER CONSTRUCTION COMPANY
2.Well Construction Permit#:
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
11/29/2021 Smith-11-21 25
(gallons per minute)"

5.Well Location
Facility/Owner Name*
Larry Smith Facility ID#
(Required) (If applicable)
County*
Beaufort
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)
6536-08-2561
Physical Address* Street Address
Tunstall Swamp Rd
Address Line 2
City State/Province/Region
Aurora INC
Postal/Zip Code Country
27806 us
Latitude* 35.2930780000 Longitude*76.8880820000
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: 1
9.Total well depth below land surface: (ft.) 9a.What is the depth of the casing from ground
218 surface?
For multiple wells list all depths if different 198
(example-3@200'and 2@100') in feet
10.Static water level below top of casing: (ft.) 11.Borehole diameter:
65 7
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)
250 13a.Method of test:
If applicable Air Lift
13b. Disinfection type:* 13b.Amount:
HTH Shock-calcium hypochlorite 1/4 pound
14.WATER BEARING/FRACTURE ZONES
From To Description
170 218 Limestone-Castle Hayne Aquifer
in feet in feet
3 20 Surface Groundwater
in feet in feet
25 37 Surficial Aquifer Zone
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
218.00 198.00 4.00 Sch.40 PVC
in feet in feet in inches
18.GROUT
.................
From To Material Emplacment Method&Amount
197.00 0.00 TD-16-.25"pellet Grout Gravity-400 pounds
in feet in feet
19. SAND/GRAVEL PACK(if applicable)
From To Material Emplacment Method
218.00 197.00 #2 Sand Gravity
in feet in feet
20. DRILLING LOG
From To Description(color, hardness,soil/rock type,grain size,etc.)
0.00 3.00 Brown Sandy Clay
in feet in feet
3.00 20.00 Light Gray Sand
in feet in feet
20.00 25.00 Gumbo Clay
in feet in feet
25.00 37.00 Gray Sand
in feet in feet

37.00 50.00 Blueish Gray Shell hash/Sand mixture
in feet in feet
50.00 110.00 Yorktown Formation-Gray fine silty sand
in feet in feet
110.00 120.00 Coquina Limestone Unit-White Chalky limestone
in feet in feet
120.00 137.00 Phosphate Ore Matrix-Black Clayey Sand
in feet in feet
137.00 170.00 Lean Ore-Tan Stiff Clay
in feet in feet
170.00 218.00 Limestone w/Sand lenses-Castle Hayne Aquifer
in feet in feet
21. Remarks
Permit No.was not printed on the Well permit form. Property is behind 1845 Tunstall Swamp road-21 Acre Farm.
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
Signature of Certified Well Contractor