GW1-2022-06367_Well Construction - GW1_20220715

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NORTH CAROLINA
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WELL CONSTRUCTION RECORD (GW-1 )
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Form GW-1 Well Construction Electronic Form
North Carolina Department of Environmental Quality
Division of Water Resources
November1
Submission ID#
G W 1-2022-06367
Are you submitting a scanned form?* Yes
No
CONTACT INFORMATION
.......................................................................................................................
Contact Name* Email Address*
Ronald Keeter [e-mail]
Is this a revision to the form you have previously submitted?*
Yes No
WELL CONSTRUCTION INFORMATION
........ ......... ........... ... ......... ..... .... ......... ......... ......... ......... ......... .........
1.Who is installing these wells?*
Owner Well Contractor
1.Well Contractor Information:
Certiticate# Cert Level First Name Last Name Company Name
2960 A RONALD KEETER,JR. SOUTHEASTERN PUMP&WELL
2.Well Construction Permit#:
356150
List all applicable well construction permits(i.e.Monitoring Wells,UIC-Underground Injection Control,CCPCUA-Central Coastal Plain Capacity Use Area,County,
etc.)
What type of well is this?* Injection Well Non-Water Supply Well
Water Supply Well(includes irrigation wells)
3.Water Supply Well* Geothermal (Heating/Cooling Supply) Industrial/Commercial
Irrigation Municipal/Public/Community
Residential Water Supply(single) Residential Water Supply(shared)
Wells> 100,000 GPD
4.Date well was completed and ID#
Date Well Completed* Well ID# Well Yield

7/21/2021 20
(gallons per minute)"
5.Well Location
Facility/Owner Name*
Antoine Moore Facility ID#
(Required) (If applicable)
County* Parcel Identification No.(PIN)
Perquimans
Physical Address* Street Address
438 Red Banks Road
Address Line 2
City State/Province/Region
Hertford NC
Postal/Zip Code Country
27944 US
Latitude* 36.2028267000 Longitude*-76.2974610000
Decimal degrees Decimal degrees
........ ................ ......... ........................... ........................... ......... ......... ......... ...................
6.Is(are)the well(s):* Permanent Temporary
7.Is this a repair to an existing well:* Yes • No
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this form.
For multiple Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction,only 1 GW-1 is needed.
8a.Indicate TOTAL NUMBER of wells drilled: 1
9.Total well depth below land surface: (ft.) 9a.What is the depth of the casing from ground
68 surface?
For multiple wells list all depths if different 58
(example-3@200'and 2@100') in feet
10.Static water level below top of casing: (ft.) 11.Borehole diameter:
10 5.875
If water level is above casing,use"+" in inches
12.Well construction method:
Auger Air Rotary Cable Tool
Direct Push Mud Rotary Rotosonic
Other
13. FOR WATER SUPPLY WELLS ONLY:
13a.Yield(gpm)
20 13a.Method of test:
If applicable pump
13b. Disinfection type:* 13b.Amount:*
HTH 1 Gallon

14.WATER BEARING/FRACTURE ZONES
From To Description
58 68
in feet in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
From To Diameter Thickness Material
0.00 58.00 1.25 21 pvc
in feet in feet in inches
17.SCREEN
...................
From To Diameter Thickness Material
58.00 68.00 1.25 40 pvc
in feet in feet in inches
18.GROUT
From To Material Emplacment Method&Amount
0.00 58.00 3/8 pour
in feet in feet
19. SAND/GRAVEL PACK(if applicable)
From To Material Emplacment Method
58.00 68.00 #3 pour
in feet in feet
20. DRILLING LOG
From To Description(color, hardness,soil/rock type,grain size,etc.)
0.00 28.00 clay and sand
in feet in feet
28.00 48.00 clay
in feet in feet
48.00 68.00 course gray sand
in feet in feet
21. Remarks
22.Site diagram or additional well details:
You may upload additional well construction information here.
pdf only
CERTIFICATION INFORMATION
.................
* By signing this form, I hereby certify that the well(s)was(were)constructed in accordance with 15A NCAC 02C.0100 or
15A NCAC 02C.0200 Well Construction Standards and that a copy of this record has been provided to the well owner.

23.Certification
Signature of Certified Well Contractor