GW1-2022-05978_Well Construction - GW1_20220617

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
John E Salmon 14.WATER ZONES
Well Contactor Name FROM TO DESCRIPTION
55 ft. 88 ft. White Lome Stone
3497 -A ft. I,
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a cable)
ARM 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,Coun(v,State,Variance,etc) 0
6 8ft. ft. 7 7/8 t SC 40 PVC
3.Well Use(check well use): ft.
Water Supply Well: 17.SCREEN
Agricultural OMunicipallPublic
FROM TO ft. ft. DIAME R SLOTSIZE ICKNESS MATERIAL
68 88 4 in. 20 1 CH 40 PVC
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
PIndustrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrl ation FROM TO MATERIAL PLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 I`• 65 f`• Bentonite Chi s Poured
Monitoring DRecovery ft. It. -
---Injection Well• - - = ft. ft. -
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3StormwaterDrainage 65 ft' 88 ft. #2 Sand Poured
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soillrock type,grain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
0 f'. 30 fL Orange Sandy Clay
4.Date Well(s)Completed: 05/06/2022 Well ID# 30 fL 55 f`' Grey Silty Sand Clay Mix
5a.Well Location: 55 1* 88 f`' White lime stone with sand
Rhonda O'Jampa ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. �+a�
110 Broadview Lane Hampstead 28443 ft. ft. -
Physical Address,City,and Zip ft. ft. J 17
Pender 3292-62-3932-0000 21.REMARKS
County Parcel Identification No.(PIN) ?.-i'•, w t+�/?^ ^
ii:l'{lriN ilil li.i� t'I'ttJ Ji..•J,.,r:'.3'JI\!
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
77°41'11" N 34021'18" wQt& 05/06/2022
6.Is(are)the well(s)oPermanent or Temporary Signa of Certified Well Contractor Date
By ning this form,I hereby certi'that the wells)was(were)consinicted in accordance
7.Is this a repair to an existing well: QIYes or MNo _ with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Nell Construction Standards and that a
If this is a repair,fill our known well construction information and explain the nature of the copy of this record has been provided to the ivell owner.
repair under 921 remarks section or on the back o f 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 I 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: 88 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-5 a 200'and 2 n 100') y p
construction to the following:
10.Static water level below top of casing: 23 (ft.) Division of Water Resources,Information Processing Unit,
Ifivarer level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 7 7/8 (in.) 24b.For Infection 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) 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