GW1-2021-02076_Well Construction - GW1_20210702

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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
60 ft. 80 ft.
3497-A J U L 0 2 2021 ft. ft.
NC Well Contractor Certification Number Unit 15.OUTER CASING for multi-cased wills OR LINER if a licable
Applied Resource ManagetlWfPtl°n Processing FROM TO DIAMETER THICKNESS MATERIAL
n\A-a Cprfion ft. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-too
2.Well Construction Permit#: -FROM I TO -- DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e. UIC,County,Slate,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 nMunicipaUPublic 60fL 8Oft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
J Industrial/Commercial D Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
- Non=WaterSupplyWell; - --- Oft. 6Oft---BentOnite -Poured
Monitoring I_J Recovery ft. ft.
Injection Well: ft. ft.
]Aquifer Recharge [ Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
3Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
J Aquifer Test �Stormwater Drainage 60ft• 80ft• #2 Poured
Experimental Technology �J Subsidence Control ft. ft.
-I Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets ifnecessa
FROM TO DESCRIPTION color,hardness soil/rock type, rain size etc.
__1 Geothermal(Heating/Cooling Return) I Other(explain under#121 Remarks)
0 ft. 10 ft. sand
4.Date Well(s)Completed: 06/24/2021 Well IDN 10 ft. 20ft• white sand clay mix
5a.Well Location: 20ft• 55ft• orange silty clay
Pelican Reef HOA 55ft• 60 ft. course sand shell mix
Facility/Owner Name Facility ID#(if applicable) 60 ft. 80 ft. limestone
1460 Royal Tern Dr. Hampstead, NC 28443 ft. ft.
Physical Address,City,and Zip ft. ft.
Pender 4215-80-9055_0000 21.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:
342544.23N 77 36 37.56 w 06/24/2021
- ----- ---- nature-of.CertifiedWell Contractor L Date
6.Is(are)the well(s) �i Permanent orITemporary
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or ONo with I5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Consiruclion 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: 80(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: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Genter,Raleigh,NC 27699-1617
11.Borehole diameter: 8 (in.) 24b. For Iniection Wells: In addition to sending the form to the address in 24a
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 Sunnlv& 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
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