GW1-2021-00581_Well Construction - GW1_20210224

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Kirk McDonald 14.WATER ZONES
Well Contractor Nam. FROM 1 TO DESCRIPTION
fl. ft.
4110-B
ft. I It.
NC Well Contractor Certification Number 15.OUTER CASING for multi•eaaed wells,ORLINER Ira It ble
Practical Environmental Solutions FROM TO DIAMETER THICKVE55 MATERIAL
ft. I D. I in. I I na
Company Name
16.INNER CASING OR TUBING eothermal closed-too
2.Well Construction Permit#: na FROM TO DIAMETER THICKVE55 MATERIAL
net all applicable well corutn crlan permits rl.e. UIC,Cnunn.Stare, variance.rte.) ft. ft. p in. I sen40
3.Well Use(check well use): ft. ft. In
Water Supply Well: 17.SCREEN
FROM TO DIAMEITR SLOT SIZE THICKNESS MAI'E:RIAL
Agncultuml ❑Municipa L'Public 1 55 ft. in.
D•S ft. 2 0001 5cM0 PVC
Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) f( ft in,
Industrial/commercial []Residential Water Supply(shared) IS.GROUT
Irtl orlon FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: I,0 ft' �•5 ff bentonne pour
K Monitoring 131ilecovery O 5 ft. v L3 ft. concrete pour
Injection Well:
ft, rt.
Aquifer Recharge ❑Groundwater Remedialion
19.SAND/GRAVEL PACK RappI C. a
Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ❑Stomrwater Drainage 5.5 "' 1.O f�' N2 torpedo sand pour
Experimental Technology ❑Subsidence Control H, f. yaiww'q, aaar
Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheen If necessary)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) FROM ft. ft.To DESCRIPT[ON(color,hardnes,sotFroc4t e, ran use,ea.)
4.Date Wells)Completed: 2 17- 21 Well lD#MW-1 ft. ft.
ft.
Sae Well Location:
Town of Kure Beach 60-0-WtX 3 2 W 2
Facility/Owner Name Facility IDN(ifapplicable) ft. ft. 1 OL
701 N. Ft. Fisher Blvd., Kure Beach, NC 28449 n. n, -
Physical Address,City,and Zip ft. ft.
New Hanover 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 14
ot'well field,one IaVlong is su0icieno 22.Certiftead
34.008445 N 77.902849 W
6.Is(are)the well(s)EK Permanent or ❑Temporary Signature ofCcri6cd Well Contractor Date
B_r signin¢this form. I hereby ,,IJ,that the well(s) wac/nrn9 nm..vaeled in acen.Eanca
7.Is this a repair to an existing well: ❑Yes or ❑K No with 15.4 NCAC 02C.0100 or 15.4 NCAC 02C 0200 WeII Consouchon Standards and that a
1f1hu u a repair.fill ran known well constn¢rion i f rmation and explain the aware niche copy/this record has been provided to the well miner.
repair under#11 remarks section or on the back o/this form.
23.Site diagram or additional well details:
8.For Creoprobe/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 anach additional pages if necessary.
dolled: ( SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �✓ (fL) 24a. For All Wells: Submit this toms within 30 days of completion of well
For multiple walls 14e1 all depths ifdQ rem(evanrpla-3@y2/00'mm2@100') construction to the following:
10.Static water level below top of casing: "� (ft.) Division of Water Resources,Information Processing Unit,
If a,,Ie..I o obove.asiay,ase 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 3.5 (in.) 24b. For Iniection Wells: In addition to sending the form to the address in 24a
auger above, also submit one copy of this fool within 30 days of completion of well
12.Well construction method: construction to the following:
(ie.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 & Iniection 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 or'die county
where constructed.
Fomi G W-I North Carolina Department of Eavironmenml Quality-Division of Water Resources Reviscd 2.22-20I6

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