GW1-2021-01566_Well Construction - GW1_20210309

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: RECEIVED
Sean Cropsey 14.WATER ZONES
Well Contractor Name ^oA� FROM TO DESCRIPTION
IV�I�R
2485-A K 9 2021 115 f` 140 f`• Limestone
ft. ft.
NC Well Contractor Certification Number Information Processing Unit
l�WR Section 15.OUTER CASING for multi-cased wells OR LINER if a licable
Applied Resource Management FROM TO DIAMETER THICKNESS MATERIAL
0 ft 120 ft 4 i" SCH 40 PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-too
2.Well Construction Permit#: EHWP-00370-2020 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
]Agricultural E]Municipal/Public 0 ft. ft. in.
_!Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial CJ Residential Water Supply(shared) 18.GROUT
lrrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Bentonite Chips Poured
= Monitoring = --Recovery- — —' --ft. ft-. ` ---`---" _ J
Injection Well:
� ft. ft.
_1 Aquifer Recharge [3Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
J Aquifer Test OStormwater Drainage ft. ft.
J Experimental Technology DSubsidence Control ft. ft.
I Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness soil/rock a rain size,etc.
El Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
0 f'• 51 Clay yellow
4.Date Well(s)Completed: 02/25/2021 Well ID# 5 ft. 25 f`- Medium sand yellow
5a.Well Location: 25 f`• 80 f`• Gray clay
Harry Cordts 80ft• 100 ft- Clay sand layers
Facility/Owner Name Facility ID#(if applicable) 100ft• 115 ft' Shells-sand layers
180 Shark Landing Rd. Hampstead, NC 28443 115 ft. 140 f`• Limestone
Physical Address,City,and Zip ft. ft.
Pender 4235-79-5694-0000 21.REMARKS
County Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one latflong is sufficient) 22.Certification:
34 27 16 N 27 32 54 W 15"41 02/28/2021
6.Is(are)the well(s)•✓I Permanent or E]ITemporary Signature of Certified Well Contracte Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [DYes or ✓No with 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
/f this is a repair,fill out known well construction information 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 I GW-I 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: 140(ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For rnulliple wells list al/depths it different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 25 (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 5 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: ry 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
13a.Yield(gpm) Method of test: 24c. For Water Supply&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: Amount: 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