GW1-2021-06994_Well Construction - GW1_20210507

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Sean Cropsey le� 14.WATER ZONES
Well Contractor Name A FROM TO DESCRIPTION
165 ft• 19411• Sandstone
2485-A
I,hAY X 7 2021 ft. ft.
NC Well Contractor Certification Number U111t 15.OUTER CASING for multi-cased wells OR LINER if a lieable
Applied Resource Mana eiHf�tlon Processing FROM TO DIAMETER THICKNESS MATERIAL
pP 9 041P section 0rt. 168ft. 4 i"• SCh 40 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Stale,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
J Agricultural DMunicipal/Public 0 174t 194ft• 2i"• 10 Sch 40 PVC
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
Industrial/Commercial ❑Residential Water Supply(shared) 1g.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: _ 0 ft. 20ff• BeptOnite-11-bags -- --- ---
Monitoring CI Recovery ft. ft.
Injection Well:
ft. ft.
_;Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
['Aquifer Storage and Recovery iJ Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
J Aquifer Test DStormwater Drainage
rt. ft.
__1 Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets ifnecessa
FROM TO DESCRWTJON color,hardness soil/rock e, hwin size,etc.
I Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
Oft• 201 Sand &Orange clay
4.Date Well(s)Completed:04/29/2021 well ID# 20ft. 30ft• Clay sand wood
5a.Well Location: 30 ft. 40 ft. Shells some clay
Tolly Spence 40 ft- 451• Coquina
Facility/Owner Name Facility lD4(ifapplicable) 45ft• 601• Shells lighter clay
2044 Washington Acres Rd. Hampstead, NC 28443 60ft• 140ft• Limestone hard soft
Physical Address,City,and Zip 140ft• 165 ft. Dark clay some sand layers
Pender 3291-06-5186-0000 21.REMARKS
County Parcel Identification No.(PIN) 165-195 Sandstone
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
34 20 12 N 77 42 22 w Sea � 05/04/2021
6.Is(are)the well(s)✓I Permanent or_�ITemporary Signature of Ce1.rtified W I Conv or Date
----
� By signing this form,I hereby cerl�that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or [allo with 15A NCAC 02C.0100 or l5A NCAC 02C.0200 Well Construction Standards and that a
If 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 421 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: 194(ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifeli ferent(example-3@200'and 1@100') construction to the following:
10.Static water level below top of casing: 151(ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b. For Iniection 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
u
12.Well construction method: Rotary 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& 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: HTH Amount: 3 D�o at 1 0g 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