GW1-2022-05984_Well Construction - GW1_20220617

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
John Salmon 14.WATERZONES
Well Contractor Name FROM TO DESCRIPTION
3497-A 65 1`' 85 f`• White Limestone
ft. ft.
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(geothermal closed400 )
2.Well Construction Permit#: EHWP-00645-2021 FROM I TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.15C,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 65 ft. 85 ft. A Y in. PVC
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
V l�
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 f`• 60 f`• Bentonite Poured
Monitoring DRecovery ft. ft.
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 [3Stormwater Drainage 60 ft. 85 f" #2 Sand Poured
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) [3Tracer 20.DRILLING LOG attach additional sheets if necessary)
-- FROM TO DESCRIPTION color,hardness,soillrock e, rain sin,etc.
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
0 f`• 10 f` Sandy topsoil
4.Date Well(s)Completed: 12/14/2021 Well ID# 10 f`• 60 f` Clay and silt
5a.Well Location: 60 f`• 65 f`• Soft limestone and shells
Coastal Realty 65 ft• 88 ft- White Limestone
Facility/Owner Name Facility ID#(if applicable) ft. ft. f
Lot 18 Pinnacle Parkway ft. ft.
If
ft.
Physical Address,City,and Zip ft.
21.REMARKS
Pender
4205-10-1244-0000 ;,:;:;,.-;1.,y
Ies, ;
County Parcel ldentificationNo.(PiN) .c ir,c::., 71:4t!'L^./�/`,rns+�„ 9
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one laMong is sufficient) 22.Certification:
34°25'47.41"N N 77040'13.07"W W ge� '!7atee" 12/23/2021
6.Is(are)the well(s):DPermanent or Temporary Signa of Certified Well Contractor Date
By signing this form,I hereby certifi,that the we//(s)was(were)constructed in accordance
7.Is this a repair to an existing well: F7Yes or EINo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Tvell Construction Standards and that a
If this is a repair,fill out known well construction h fornalion and explain the nature of the copy of this retard has been provided to the well owner.
repair under#21 remarks section or on the back o(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-I 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: 85 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells fist all depths ifd8erent(example-3@a 200'and 2 tt 100') construction to the fallowing:
10.Static water level below top of casing: 12 ,(ft.) Division of Water Resources,Information Processing Unit,
Ifwaier 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
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method Mud ROtarV 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: Airlift 24c. For Water Supply& Injeciion 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: HtH Amount: 20 o�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