GW1-2022-08248_Well Construction - GW1_20220516

,Pr.int Form4
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
John E Salmon 14.WATER ZONES t
Well Contractor Name FROM TO DESCRIPTION
3797-A 30 ft 60 ft White Limestone
ft ft
NC Well Contractor Certification Number 15.OUTER CASING for multi cssed'wells OR LINER if a" livable '
Applied Resource Management, PC FROM TO DIAMETER THICKNESS MATERIAL '
Company Name 0 ft 40 ft 4 !" SCH 40 PVC
16.INNER CASING:OR TUBING eothermalclosed=la'o" a
2.Well Construction Permit#: EHWP00666-2021 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Counrv,State, Variance,etc) ft ft in.
3.Well Use(check well use): ft ft in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public 40 ft- 60 ft 4 in. 10 SCH 40 PVC
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
IrrI ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 38 ft Bentonite Poured
Monitoring DRecovery ft ft
Injection Well:
ft ft
Aquifer Recharge ®Groundwater Remediation
19,SAND/GRAVEL PACK'(if a' livable
Aquifer Storage and Recovery OSalinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage 38 ft 60 ft #2 Sand Poured
Experimental Technology O]Subsidence Control & ft
Geothermal(Closed Loop) OTracer 20.DRILLING LOG'attach additioniil sheets ifuecess
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRD TION color,hardness,soittrock type,grain size,etc.
0 ft 10 ft Sand
4.Date Well(s)Completed: 2/10/22 Well ID# 10 ft 20 ft Silty sand
5a.Well Location: 20 ft. 30 ft Grey clay
Ron Weaver 30 ft ft
Facility/Owner Name Facility ID#(if applicable) ft &
202 Holiday Drive ft ft
Physical Address,City,and Zip ft ft ln#ororiabon Prmo&wq Unit
Pender 3283-23-6390-0000 21-REMARKS r t
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:
77 43 54.054 N 34 23 2.706 W g��
(rSa ,dam 2/10/22
6.Is(are)the well(s)inPermanent or OTemporary Sio6ature of Certified Well Contractor Date
By signing this form,1 hereby certi)5,that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ©IYes or Callo with 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction it formation and explain the nature of the copy 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:
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: 60 (ft-) 24s. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iJ diifferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 7 7/8 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Mud Rota above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: 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
13s.Yield(gpm) 60 Method of test: Airlift 24c. For Water Suyoly&Infection 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: 20% 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