GW1-2023-02789_Well Construction - GW1_20230417

WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information:
Mike Hager 44.MATER ZONER,'2,
Well Contractor Name FROM TO DESCPJPnON
40 50- ]Sandstone-
4261-A ft. ft. I �
NC Well Contractor Certification Number 415m.OUTEltCASING(f6i DR'LINER.Of4opfiiable)
W-M- TO MWPI MCKTIMS I MATERIAL
Lloyd Well Drilling 0 ft. fL in.
Company Name I 46.'INNEIUCASING'Olt TURINGIii6thO...A clo'sed4o6by',
2.Well Construction Permit FROM ft.- TO ft. DIAMETER in. THICNAESS MATERIAL
List all applicable well construction permits e.UIC,County,State,Variance,etc.)
3.Well Use(check well use): % M in.
A7.'SCRE -
Water Supply Well: FROM MI TO K DIAMETER SLOT SUE THICKNESS I MATERIAL
DAgricultural 0Municipal/Public ft % 4 in. .010 ISch 40 JPVC
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single)
Orustrial/Commercial OResidential Water Supply(shared)
Irr, ation OWells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 20 fL Quick Grout Pump 3 bags
OMonitoring ORecovery ft %
Injection Well: ft. fL
EjAquifer Recharge OGroundwater Remediation
DAquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
E]Aquifer Test 13Stormwater Drainage 35 50 'L #2 sand JPour
OExperimental.Technology OSubsidence Control ft. ft. I
oGeothermal(Closed Loop) OTracer 7,20.-,,D LOG`(6tib r h1d Mid 6a I-a he-e Wir 11-e c--ess'-
OGeothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCPHMON(color,hardness,saftock type,grain size,etc.)
0 ft- 10 fr- Dense red clay
4.Date Well(s)Completed:4-6-23 weHD# 10 ft- 15 fL Sandy red clay
5a.Well Location; 15 fL 30 % Blue clay
Jake Szczygridl -30 40 ftCoarse Sand
Facility/OwnerName Facility ID#(ifapplicable) 40 ft. 50 Sandstone
2051 Hwy 43 Vanceboro NC 28586 M %
Physical Address,City,and Zip fL ft. APR 1 7 2023
X
Craven 1-053-060
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22. C on:
35.343369 N -77.183770 W
6.Is(are)the well(s): tPermanent or OTemporary -tignature f *fled Well ntractor Date
BY =ereby certiy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: OYes or MNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the 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 construction info
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:50 Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@100)
10.Static water level below top of casing: 14 24a. For All Wells: Original form to Division of Water Resources (DWR),
7
-(ft.)lfwater level is above casing,use Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 8 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
(in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Mud Rotary 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
I
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm)40 - Method of testAir Lift Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Chlorine Amount: 1 oz
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018