GW1-2022-07420_Well Construction - GW1_20220530

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
KENNY SARGENT 14.WATER ZONES
Well Contractor Name FROM TO I DESCRIPTION
ft. ft.
A -4226 a P ft. ft.
NC Well Contractor Certification Number "�° ..�
15.OUTER CASING for
multi-cased.wells O
FROM DIMETER RR a licable
GEOLOGIC EXPLORATION MATERIAL
ft. I ft. in.
Company Name M A
16.INNER CASING OR.TUBING eothermal closed-loon)
2.Well Construction Permit#: 75-.;;,;�:+r.g urn FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U/ 712y� tG.Yg�u�iJi�e etc.) 0.0 ft- 105.0 ft- 2.0 1°' SCH 40 PVC
3.Well Use(check well use): 1 !l•l % ft• '"•
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaVPublic 105.0 ft' 110.0 ft. 2.0 1a' .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18."GRO0T:
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0,0 ft. 97.0 ft' PORTLANDaENTONITE SLURRY
Monitoring ❑Recovery I.
ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
El Aquifer Storage and Recovery [I Salinity Barrier FROM TO I MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 103.0 It- 110.0 ft- 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiL/mck type,grain size,etc.
0.0 ft- 4.0 ft- GRASS/BACKFILL
4.Date Well(s)Completed: 02/23/22 Well ID# IR 89-MW-113MCH 4.0 ft. 16.0 ft- BLACK SANDY SILT
5a.Well Location: 16.0 ft 50.0 ft- BROWN SANDY SILT/SHELLS
CAMP LEJEUNE - SITE 89 50.0 It' 70.0 ft- BROWN/WHITE SANDY LIMESTONE
Facility/Owner Name Facility ID#(ifapplicable) 70.0 It- 97.0 ft- I BROWN/GRAY SANDY CLAY
2720 PINEY GREEN ROAD JACKSONVILLE 28547 97.0 ft- 110.0 ft• WHITE SANDY LIMESTONE
Physical Address,City,and Zip ft. ft.
ONSLOW 21.REMARKS ..'
County Parcel Identification No.(PIN) BENTONITE-SEAL-97.0-103.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat(long is sufficient) 22.Certification: J
340 43' 17.98" N 770 19' 15.28" W / .4..
03/17/22
6.Is(are)the well(s): IMPermanent or []Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby cer!(;y that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the oflhis record has been provided to the well owner.
repair under#21 remarks section or on the back of 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 construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Ove?in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 110.0 (ft.
For multiple wells list all depths ifdi,/ferent(example-3@200'and 2@100) ) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 10.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwaterleve!is above casing,use"+"
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6.0 (in) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: SONIC
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018