GW1-2022-05983_Well Construction - GW1_20220617

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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
3497-A 55 f` 75 f`' White Limestone
fr. fr.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR LINER if a able)
Applied Resource Management FROM TO DIAMETER lic
THICKNESS MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: EHWP-00647-2021 FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County.State, variance,etc) +1 �ft55 ft' 4 '"' 80 PVC
3.Well Use(check well use): ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipaVPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) 55 ft' 75 rt' 2 '"' 20 80 PVC
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 50 ft. Bentonite Poured
Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery [ISalinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage 50 ft. 75 ft. #2 Sand Poured
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary
Geothermal(Heating/Cooling Return) TO DESCRIPTION(color,hardness,soiUmck e, rain size,etc.)) ,Other(explain under#21 Remarks) 0
ft. 10 ft. Orange clay sand
4.Date Well(s)Completed: 1/06/2022 Well ID# 10 ft. 40 ft. Grey sand silt
Sa.Well Location:
40 ft. 50 ft- Shells coarse sand, limestone
Coastal Realty 50 ft 75 fr. White Limestone
Facility/Owner Name Facility ID#(ifapplicable) ft. ft
Lot 3 Union Bethel Road, Hampstead, NC 28443 ft. ft.
Physical Address,City,and Zip ft. ft. 7
Pender 4214-35-6631-0000 21.REMARKS
County Parcel Identification No.(PIN)
ii:�i.I; r;,riil�' !1'I•�1.;(::`-.`i;`,'i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �U\�
(ifwell field,one lat/long is sufficient) 22.Certification:
77 37 42.340 N 3425 2280 W "'nb� ���
�,j' 1/6/2022
6.Is(are)the well(s)oPermanent or Temporary Sign6Krc ofCertified Well Contractor Date
By signing this form,I hereby certi,that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: r1IYes or MNo with 15A NCAC 02C.0100 or 15A NCAC 02C'.0200!hell Construction Standards and that a
ifthis 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 921 remarks section or on the back of this.jonn.
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 muhiplc wells list all depths if different(example-3 a.200'ami 2 tt!00') construction to the following:
10.Static water level below top of casing: 12 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 7 7/8 (in.) 24b.For injection 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) 60 Method of test: Airlift 24c. For Water SunDly&Injection 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: I-ItI-I Amount: 20�0 completion of well construction to the county health department of the county
where constructed. I
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016