GW1-2022-07911_Well Construction - GW1_20220823

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: I�
1.Well Contractor Information:
DAVID HALL 14.WATER ZONES I i
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
A - 4459 a. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR L[NER ifa licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. I ft. 1 1 'in.
Company Name 16.INNER CASING OR TUBING 'eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) 0.0 ft. 5.0 ft. 2.0 i in. SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
PPy FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5.0 ft' 15.0 ft' 2.0 1n. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water,Supply(single) tr, tt. in•
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑lrrl atlon ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 fL 3.0 fL PORTLAND BENTONITE SLURRY
OMonitoring ❑Recovery D, ft.
Injection Well:
tt. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑StormwaterDrainage 4.0 ft• 15.0 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/rock type,gmin size,etc.
0.0 ft• 5.0 fr, CLAY
4.Date Well(s)Completed: 08/01/22 Well ID# ASP-MW-3 5.0 e• 15.0 ft• SILTY SAND
5a.Well Location:
HARVEY POINT FEDERAL FACILITY rt. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
2835 HARVEY POINT ROAD HERTFORD 27944 ft. ft.
Physical Address,City,and Zip ft. ft.
PERQUIMANS 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL 3.0 4.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat(long is sufficient) 22.Certification:
360 05' 47.22" N 760 19' 36.23" W 08/16/22
6.Is(are)the well(s): (EPermanent or ❑Temporary Signature of Certified Well Contractor Dace
By signing this form,I hereby certify that the wel/(s)was(were)constructed in accordance with
7.
Is this arepair to an existing well: ❑Ves or MN� 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Cons i�tgrrdyg&`s 'h
/'this is a repair,fill our known well construction information and explain the nature oJ the of this 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: It �� t
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additiorlal1,7well 6%ns1ruJ0r&0
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: Info.ri�ila on Priomning Und
24.SUBMITTAL INSTRUCTIONS [ANQ/3OG
9.Total well depth below land surface: 1 5'0 (ft.)
Tor muhiple we/Ls list a//depths ifd ereni(example-3 rem 200'and 1@1001 Submit this GW-1 within 30 days of well completion per the following:
6.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
ll"water level is above casing,use"4 i
11.Borehole diameter: 8.0 (in.) 24b. For Injection Wells:Copy to�DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
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 producing over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018