GW1-2022-01754_Well Construction - GW1_20220203

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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
40ft 60 ft Course Sand with Layered Concreted
3497-A ft ft
Limestone
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 eother al closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) ft ft in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public 40ft. 60ft• 4 in. 10 Sch 80 PVC
Geothermal(Heating/Cooling Supply) [Residential Water Supply(single) ft. ft.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
hrl atlon FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 40 ft bentonite chips Poured
Monitoring ORecovery ft. ft.
Injection Well: ft. ft.
PAquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
�IAquifer Storage and Recovery [:)Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
�IAquifer Test [Stormwater Drainage 40 ft. 60 ft- #sand Poured
Experimental Technology [Subsidence Control ft. ft.
Geothermal(Closed Loop) [Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock e, rain size,etc.)
GNeothermal(Heating/Cooling Return) Other(explain under#21 Remarks) 0 ft. 10 ft. Orange sand
4.Date Well(s)Completed: 10/25/2021 Well ID# 10 ft. 30 IL Brown sand clay mix
5a.WellLocation: 30 ft. 40ft• Fine grain red sand
Timeless Properties 40ft• 60 It. Course Sand with Layered Concreted
Facility/Owner Name Facility ID#(if applicable) ft. ft. Limestone
10401 Royster Road NE 28451 60ft• 75ft. Gray clay with sand
Physical Address,City,and Zip ft. ft.
Brunswick 21.REMARKS
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:
N W gtt& C-�a&e'g' 10/25/2021
6.Is(are)the well(s)OPermanent or [3Temporary S' ature 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: QYes or [3No with 15A NCAC 02C.0100 or 15A NCAC 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#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 INSTRUCTIONS
9.Total well depth below land surface: 60 (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: 12 (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: 7 7/8 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: Mud Rotary above, also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 19 Method of test: Air Lift 24c.For Water Supply&Iniection Wells: In addition to sending the form to
o the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HtH Amount: 20�o completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016