GW1-2021-02444_Well Construction - GW1_20210901

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_ 1
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
John Salmon �4"�' >�„` �� 14.WATER ZONES
Well Contractor Name a w v FROM TO DESCRIPTION
3497-A
,1 2021 55 ft- 75 It- limestone
S t� r. - ft. ft.
NC Well Contractor Certification Number n.0 r�ti(j, Vl},
15.OUTER CASING for mti-cased wells OR LINER if o licable
FROM
Applied Resource Manageml fi��,''=� � '' n To tilDIAMETER TI�C.NESs 11fATERIAL
Company Name ~
E H WP-00565-2021 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit 4: FROM TO DIAMETER THICKNESS 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.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural nMunicipal/Public 55 fL 75ft. 4i" 20 Sch 80 PVC
Geothermal(Heating/Cooling Supply) BResidential Water Supply(single) fL ft in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
I73irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 55 fL Bentonite Poured
:-)Monitoring (_I Recovery ft. ft.
Injection Well:
ft. ft.
-'Aquifer Recharge- [3Groundwater Remediation- -
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
3 Aquifer Test OStormwater Drainage 55ft- 75 ft- #2 Poured
J Experimental Technology 0J'Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION Cohn•,hardness,soil/rock a rain size etc.
J Geothermal(Heating/Cooling Return) Other(explain under#121 Remarks)
oft. 10 ft• orange clay sand
4.Date Well(s)Completed: 08/26/2021 Well ID# 101. 40 ft- grey sand silt
5a.Well Location: 40ft' 50ft. shells course sand
Matthew Sawyer 50ft' 75 ft- limestone
Facility/Owner Name Facility lD4(ifapplicable) ft. ft.
Lot 3 Union Bethel Rd. Hampstead, 28443 ft. ft.
Physical Address,City,and Zip ft. ft.
Hampstead p�� (�y 4214-35-6631-0000 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:
77 37 42 340N 34 252 280 W ciz& 157a e4l 08/26/2021
6.Is(are)the well(s)•DPermanent or ❑ITemporary S' ature of Certified Well Contractor Date
By signing this form, I hereby certifv that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E]Yes or BNo with I5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If rhi.s 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 421 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: 75(ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3@200'and 2@I00') 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: 8 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Mud Rota above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: Rotary 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) 60 Method of test: Air Lift 24c. For Water Sunoh'& Injection 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: I-Itl 1 Amount: 20�� 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