GW1-2022-07910_Well Construction - GW1_20220823

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information:
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DAVID HALL 14.WATER ZONES 1 {
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
A - 44S9
NC Well Contractor Certification Number 15.OUTER CASING for mu1N-cased wells OR LINER if a livable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. rt.
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Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC.County,State,Variance,etc.) 0.0 ft- 7.0 ft' 2.0 in' SCH 40 PVC
ft. ft.
3.Well Use(check well use): in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 7.0 ft' 17.0 ft' 2.0 in• .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. it. in;
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl atlon ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT M ETHOD&AMOUNT
Non-Water Supply Well: 0.0 fr. 3.0 ft. PORT ANDBENTONRE SLURRY
(EMonitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL.PACK(if a lieable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage 5.0 ft• 17.0 fL 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control fr. fr.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG'attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soil/rock e, min size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
0.0 ft• 5.0 ft' CLAY
4.Date Well(s)Completed: 08/03/22 well ID# ASP-MW-1 5.0 ft• 17.0 ft' SILTY SAND
ft. ft.
5a.Well Location:
ft.
HARVEY POINT FEDERAL FACILITY ft.
Facility IDt!(if ft. ft.
Facility/Owner Name
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2835 HARVEY POINT ROAD HERTFORD 27944
Physical Address.City,and Zip ft. ft. 1r1fQF�rtilf�i.�1 3f��iR
PERQUIMANS 21.REMARKS
BENTONITE SEAL-3.0-5.0 FEET
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
36° OS' 47.22" N 760 19' 36.23" W 08/16/22
Signature of Certified Well Contractor Date
G.Is(are)the well(s): Permanent or ❑Temporary
By signing this form,I hereby centfy that the well(s)was(here)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or [5No 15A NCAC 02C.0I00 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
lfthis is a repair,Jill out known well construction information and explain the nature of the oJ7his record has been provided to the well owner.
repair under"2I remarks section or on the back of this Jorm.
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 I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 17.0 (ft.)
Fur multiple woMy list all depths lJ'different(example-3 rt 200'and 2 a 100') Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 6'0 (ft') Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" i
24b. For Infection Wells:Copy to'DWR,Underground Injection Control (IUC)
11.Borehole diameter: $'0 (in.) Program,1636 MSC,Raleigh,NC27699-1636
12.Well construction method: AUGER 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 producinE over]00,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-161 1
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018