GW1-2022-07986_Well Construction - GW1_20220831

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1. Well Contractor Information:
John E. Salmon 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
3497 - A
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
Applied Resource Management FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. I in.
Company Name
OS WP WP-22-0110 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit 4: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. UC,County,State, Variance,etc.) 0 ft. 180 ft. 4 in. Seh 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 180ft. 200 fL 4 in. .010 Sch 40 PVC
Geothermal(Heating/Cooling Supply) 10IResidential Water Supply(single) ft B, in.
�Industrial/Commercial [:]IResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
]Non-Water Supply Well: 165 ft 175 ft- Bentonite Poured
Monitoring DRecovery 0 ft. 30 ft. Bentonite Poured
Injection Well:
LJft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
®]Aquifer Storage and Recovery 01 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
rJAquifer Test [:]I Stormwater Drainage 175 ft. 200 ft. #2 Silica Poured
Experimental Technology [:]I Subsidence Control
r]Geothermal(Closed Loop) [:IITraeer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) FROM TO DESCRIPTION(color,hardness,wil/rock e,grain size,etc.]Other(explain under#21 Remarks) O ft. 22 ft.
Sands /clay
4.Datewen(s)Completed: 8/30/2022 sell IDa 22 ft 30 ft. Limestone weathered
5a.Well Location: 30 ft. 90 ft. Clay small sand lenses
Johnathan Wrenn 90 ft 120 ft Limestone (soft)
Facility/OwnerName Facility ID#(ifapplicable) 120 ft. 170 ft. Mud rock/ clay
220 Sea Gull Lane, Wilmington, NC 28409 170 ft' 200 ft' Sandstone
Physical Address,City,and Zip
New Hanover R07616-003-001-002 2L REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
34 07' 56.79" N 077 52' 14.10" wg�� �'�:�me� 8/30/2022
6.Is(are)the well(s):[R]Permanent or DITemporary Signa e of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E]IYes or ®No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature of the copy ofthis record has been provided to the well owner.
repair under 421 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 site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 200 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3CJ)200'and 2@100') construction to the following:
10.Static water level below top of casing: 24 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing use'—" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: $ (in.) 24b. For Iniection Wells: hi addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method Mud Rotary construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 60 Method oftest: Air Lift 24c. For Water Supply& Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HtH Amount: 1 lb completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016