GW1-2022-09768_Well Construction - GW1_20221102

w
®,
NORTH CAROLINA
ilk
WELL CONSTRUCTION RECORD (GW-1 )
EnvfronmertmfQua(Iry
Form GW-1 Well Construction Electronic Form
North Carolina Department of Environmental Quality
Division of Water Resources
November1
Submission ID#
G W 1-2022-09768
Are you submitting a scanned form?* Yes
No
CONTACT INFORMATION
.......................................................................................................................
Contact Name* Email Address*
Mike Hager [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
4261 A MICHAEL HAGER LLOYD WELL DRILLING
2.Well Construction Permit#:
348913
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.Water Supply Well* Geothermal (Heating/Cooling Supply) Industrial/Commercial
Irrigation Municipal/Public/Community
Residential Water Supply(single) Residential Water Supply(shared)
Wells> 100,000 GPD
4.Date well was completed and ID#
Date Well Completed* Well ID# Well Yield

9/13/2022 100
(gallons per minute)"
5.Well Location
.....................................................................................................
Facility/Owner Name*
Kameron Gwynn Facility ID#
(Required) (If applicable)
County*
Carteret
The selected county is within the Central Coastal Plain Capacity Use Area. Please reference your Capacity Use Water
Withdrawal Permit Number(CUxxxx)in Section 2.above.
Parcel Identification No.(PIN)
840703228179000
Physical Address* Street Address
106 Sandy Landing Road
Address Line 2
City State/Province/Region
Cedar Island NC
Postal/Zip Code Country
28520 us
Latitude* 35.0178317000 Longitude*76.3177542000
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: 1
9.Total well depth below land surface: (ft.) 9a.What is the depth of the casing from ground
90 surface?
For multiple wells list all depths if different 80
(example-3@200'and 2@100') in feet
10.Static water level below top of casing: (ft.) 11.Borehole diameter:
5 4
If water level is above casing,use"+" in inches
12.Well construction method:
Auger Air Rotary Cable Tool
Direct Push Mud Rotary Rotosonic
Other
13. FOR WATER SUPPLY WELLS ONLY:

13a.Yield(gpm)
100 13a.Method of test:
If applicable Air Lift
13b. Disinfection type:* 13b.Amount:
Chlorine 2 oz
....................................................................
14.WATER BEARING/FRACTURE ZONES
From To Description
80 90 Limestone
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
80.00 90.00 4.00 Sch 40 PVC
in feet in feet in inches
18.GROUT
.............................
From To Material Emplacment Method&Amount
0.00 20.00 Quick Group Pump-4 bags
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 10.00 Sand and Organics
in feet in feet
10.00 20.00 Sand
in feet in feet
20.00 50.00 Sand&Shells
in feet in feet
50.00 74.00 Sand/Shells/Blue Clay
in feet in feet
74.00 90.00 Limestone
in feet in feet
21. Remarks
...............................................................................

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
Ake #dger
Signature of Certified Well Contractor