GW1-2022-05992_Well Construction - GW1_20220617

WELL CONSTRUCTION RECORD(GW-1), For Internal Use Only: Print Form
1.Well Contractor Information:
John Salmon 14.WATERZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
3497-A
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased wells OR LINER if a licable)
ARM FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING eothermal closed-loon)
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,Comav,State,Variance,etc.J O ft. 2 5 0 ft. 1 in- S D R-1 1 H D P E
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) t8.GROUT
Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0ft. 9,56 ft. Bentonite Tremi
Monitoring Recovery ft. ft.
Injection Well:
ft, ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO I MATERIAL I EMPLACEMENT METHOD
Aquifer Test E3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) [ITracer 20.DRILLING LOG attach additional sheets if necessary
FROM TO DESCRIPTION color,hardness,soillrock e, rain size etc.
Geothermal(HHeating/Cooling Return) ;Other(explain under#21 Remarks) 0 ft. 10 ft. Sand
4.Date Well(s)Completed: 2-1-22 Well ID# 10 ft. 65 ft. Clay and Sand
Sa.Well Location: 65 f`• 160 f`
David White 160 f` 1 250 f` Gray Clay
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
215 Windchase Lane ft. ft.
Physical Address,City,and Zip ft. ft.
New Hanover R07200-005-023-000 21.REMARKS 'r`3'7.., or .
f f "� t;/r i I
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: s I
(ifwell field,one Iat/long is sufficient) 22.Certification:
340 9'35.24" N 77-51-20.49"
Ii�Y{�>wi�,siC- J 2�02'/,�172Q22i
6.Is(are)the well(s) foPermanent or OTemporary Signatu fCertified Well Contractor Date
By signing this form,I hereby certh,that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: E©IYes or K)No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Nell Construction 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 tinder#21 remarks section or on the back o(Ihis 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 SiW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: L} SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 250 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For nnuhiple wells list all depths ifdierent(example-3@200'and 2@l00') construction to the following:
10.Static water level below top of casing: 15 (ft.) Division of Water Resources,Information Processing Unit,
Ifwaierlevel is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: Mud Rotaryabove, 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& Infection 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-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016