GW1--06913_Well Construction - GW1_20231030

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Jimmy Morris 14iWATER2ONES - -,` f•-." - . • -- .
FROM TO DESCRIPTION
Well Contractor Name
4193-A 107 ft- 155 ft- LireStone
ft. ft.
NC Well Contractor Certification Number 15.-OUTER•CASING-(for multi=cased Bells)OR LINER(if ap licable)
M ag ette Well & Pump Co FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft- 40. ft- 30 I in- j.375 Steel
16.INNER CASINGORTUBING(geothermal closed-loopy. • -
2.Well Construction Permit#: FROM. TO DIAMETER THICKNESS MATERIAL
List oil applicable well construction permits(i.e.U1C,County,State,Variance,etc.) +4 ft, 107 ft- 20 j 'rt' SCH 10. 316 SS
3.Well Use(check well use): ft. ft. ( in.
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL-
[Agricultural lhMunicipal/Public 107 ft. 155 ft. 19 T. Open Hole
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. 107 fa
❑IndustriaVCommercial ❑Residential Water Supply(shared) 18.GROUT` - _. . • •$.: ' .-
Dlrrigation ❑Wells>100,000-GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft* 107 . ft' Neat Cement Tremie
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer•Recharge ❑Groundwater Remediation - - -
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
OGeothermal(Closed Loop) ❑Tracer 20.DRILLING.LOG(attach additional sheets if necessary) -- - -
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size.etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) IL ft.
4.Date Well(s)Completed: 9/19/2023 Welt ID#Wel 16 ft. ft.
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5a.Well Location: ft, ft.
Town of Surf City ft ft. a'_,x :,,,, y,7 p
Facility/Owner Name Facility ID#(if applicable)
ft. ft. , c 1. ter•`if.,-r1 ii 1„..,II ,r, •
1 Juniper Trail, Surf City, NC 28445 : ft. ft. ? . OCT 3 0 2023
ft. ft,
Physical tAddress,City,and Zip irk!..:,...,.....,,d , :,;.,,�,,;,, i�, .
Pender 21.REMARKS, ` ,
• C' w- J
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: .
(if well field,one lat/ong is sufficient) 22.Certification:
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34.444637 N -77.558853 W
/a//2/2?
c
6,Nam)the well(s): f�JPermanent or ❑Temporary nature of Certi fed Well Contractor Date
- -E-ysir- rhis form,f hereby cent&that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or h!No 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 1 GW-1 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: 155 (ft) Submit this GAT-1.within 30 da'ys of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@100')
21.21 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft•) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"-,"
24b.For Injection Wells: Copy1 to DWR,Underground Injection Control(IUC)
11.Borehole diameter: 29 (in.) Program,1636 MSC,Raleigh,NC 27699-1636
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12.Well construction method: 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
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm)
34.28 G/FDD Method of test: Draw Down Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 3 LBS
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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