GW1-2022-09653_Well Construction - GW1_20221027

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NORTH CAROLINA
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WELL CONSTRUCTION RECORD (GW-1 )
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Form GW-1 Well Construction Electronic Form
North Carolina Department of Environmental Quality
Division of Water Resources
November1
Submission ID#
G W 1-2022-09653
Are you submitting a scanned form?* Yes
No
CONTACT INFORMATION
.......................................................................................................................
Contact Name* Email Address*
Corey Gamwell [e-mail]
Is this a revision to the form you have previously submitted?*
Yes No
WELL CONSTRUCTION INFORMATION
........ ......... ........... ... ......... ..... .... ......... ......... ......... ......... ......... .........
1.Who is installing these wells?*
Owner Well Contractor
1.Well Contractor Information:
Certiticate# Cert Level First Name Last Name Company Name
3027 A COREY GAMWELL GROUND ZERO ENVIRONMENTAL
FIELD SERVICES
2.Well Construction Permit#:
......................
WM07011287
List all applicable well construction permits(i.e.Monitoring Wells,UIC-Underground Injection Control,CCPCUA-Central Coastal Plain Capacity Use Area,County,
etc.)
What type of well is this?* Injection Well Non-Water Supply Well
Water Supply Well(includes irrigation wells)
3.Non-Water Supply Well* Monitoring
Recovery
4.Date well was completed and ID#
......... ......... ......... ......... ..... .........
Date Well Completed* Well ID# Well Yield
10/14/2022 GW1-3 (gallons per minute)"

5.Well Location
Facility/Owner Name*
Justin Old Facility ID#
(Required) (If applicable)
County* Parcel Identification No.(PIN)
Currituck 0009000025A0000
Physical Address* Street Address
Baxter Lane
Address Line 2
City State/Province/Region
Moyock NC
Postal/Zip Code Country
27958 Currituck
Latitude* 36.5383170000 Longitude*76.1847014000
Decimal degrees Decimal degrees
6.Is(are)the well(s):* Permanent Temporary
7.Is this a repair to an existing well:* Yes No
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this form.
For multiple Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction,only 1 GW-1 is needed.
8a.Indicate TOTAL NUMBER of wells drilled: 3
9.Total well depth below land surface: (ft.)
3@6 ft 9a.What is the depth of the casing from ground
surface?
For multiple wells list all depths if different
(example-3@200'and 2@100') in feet
11.Borehole diameter:
10.Static water level below top of casing: (ft.) 1.5
If water level is above casing,use"+" in inches
12.Well construction method:
Auger Air Rotary Cable Tool
Direct Push Mud Rotary Rotosonic
Other
14.WATER BEARING/FRACTURE ZONES
From To Description
3 6 Wet sand
in feet in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
From To Diameter Thickness Material
in feet in feet in inches

17.SCREEN
From To Diameter Thickness Material
2.00 6.00 0.75 Stainless Steel
in feet in feet in inches
18.GROUT
From To Material Emplacment Method&Amount
in feet in feet
19. SAND/GRAVEL PACK(if applicable)
From To Material Emplacment Method
in feet in feet
20. DRILLING LOG
From To Description(color, hardness,soil/rock type,grain size,etc.)
0.00 6.00 sand,wet at 2 ft
in feet in feet
21. Remarks
Three water samples were taken using the Geoprobe screen point water sample tool.After collecting each water sample
the tooling was removed from the ground and the sample locations were abandoned with grout.
22.Site diagram or additional well details:
You may upload additional well construction information here.
pdf only
CERTIFICATION INFORMATION
* By signing this form, I hereby certify that the well(s)was(were)constructed in accordance with 15A NCAC 02C.0100 or
15A NCAC 02C.0200 Well Construction Standards and that a copy of this record has been provided to the well owner.
23.Certification
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Signature of Certified Well Contractor