GW1-2022-07915_Well Construction - GW1_20220823

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID HALL 14.WATER ZONES ss
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 4459 rt. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for mufti-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. I I. 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. 6.0 ft. 2.0 in. SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER'' SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 6.0 rt' 16.0 ft' 2.0 in: .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl atlon ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 3.0 ft' PORTANDBENTONITE SLURRY
OMonitoring ❑Recovery
Injection Well:
ft. ft.
❑Aquiter Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK ifa licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Storimwater Drainage 4.0 tt• 16.0 tt. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)'
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) FROM TO DESCRIPTION color,hardness,soil/mck type,grain sim,etc.
0.0 ft- 16.0 ft. SILTY SAND
4.Date Well(s)Completed: 08/02/22 Well ID# SDS-MW-2 ft. ft.
ft. ft.
Sa.Well Location:
HARVEY POINT FEDERAL FACILITY ft. ft.
Facility/Owner Name Facility ID#(if applicable)
rt. a. j
2835 HARVEY POINT ROAD HERTFORD 27944 fr. 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 { Date������'''``````
Hy signing thin'form,1 hereby certl/y that the we//(v)was(u,R, tc•ted •o !t r+�• h
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 15A NCAC 02C'.0200 Well Cons ru r%�,�i a $d i at
lfthis is a repair,fill out known ire/l construction information and explain the nature ofihe of7hls record has been provided to the well owner. t
repair under#21 remarks section or on the back g1lhis form. Aii r •: 2022
23.Site diagram or additional well details:
You may use the back of this page;to provide additional well st
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same •� . }� v f V
(add'See Over'in Remarks Box).You may also atIAMEk1l;?il ce q�.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells rasp
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 16.0 (ft.)
Fbr multiple wells list all depths ifd/#ereni(example-3@200'and 2 rr 100') Submit this GW-1 within 30 days'of well completion per the following:
10.Static water level below top of casing: 6•0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
//baler level is above casing,use"+ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
IL 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 I ver 100,000 GPD: Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-161 1
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
j
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources! Revised 6-6-2018