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Home My WebLink AboutGW1-2021-00191_Well Construction - GW1_20210505 Print Form WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: 1.Well Contractor Information: Sean Cropsey p= a�l 14.WATER ZONES Well Contractor Name �rO FROM TO DESCRIPTION f O s��' 2485-A 2021 38ft- 80ft• Limestone YI� ft. ft. NC Well Contractor Certification Number 1 LITER CASING for multi-cased wells OR LINER if a livable �. �-1 71��5'�•' FROM TO DIAMETER THICKNESS MATERIAL Applied Resource Management Irkll1= iml I r,� n dg^i!t111 ft. ft. in. Company Name EHWP-00880-2020 16.INNER CASING OR TUBING eothermal closed-loop) 2.Well Construction Permit#: FROM TO DIAMETER TIHCKNESS MATERIAL List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) 0 ft. 60 ft• 4'n• Seh 40 PVC 3.Well Use(check well use): ft. ft. in. 17.SCREEN Water Supply well: Pp y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL 71JAgricultural [3Municipal/Public 0 60ft 80' 4in. 20 Sch 40 PVC (_,Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft. in. Industrial/Commercial Residential Water Supply(shared) 18.GROUT _I Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT Non-Water supply well: Oft• 20ft• Bentonite 8 bags :'Monitoring Recovery ft. ft. - Injection Well: -- ft. ft. _ Aquifer Recharge DGroundwater Remediation 19.SAND/GRAVEL PACK if applicable) ( Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD J Aquifer Test Stormwater Drainage 60 ft- 80 ft- ##2 Poured Experimental Technology �]!1 Subsidence Control ft. ft, ]Geothermal(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) 30ther(explain under#21 Remarks) 0 ft. 5ft. Clay 4.Date Well(s)Completed:04/19/2021 Well ID# 5ft. 151. Sand 5a.Well Location: 151• 30f'• Clay some shells Bobby Rosinbaum 30ft• 38f'• Shells to limestone Facility/Owner Name Facility lD4(if applicable) 38ft. 80" Limestone 325 Holiday Dr. Hampstead, NC 28443 ft. ft. Physical Address,City,and Zip ft. ft. Pender 3283-45-3242-0000 21.REMARKS County Parcel Identification No.(PIN) 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (if well field,one tat/long is sufficient) 22.Certification: 34 23 23 N 77 43 36w , 04/27/2021 �z 2AeA 6.Is(are)the well(s)QPermanent or OTemporary Signature of Certified Well Cofactor Date By signing this form,I hereby certfv that the wells)was(were)constructed in accordance 7.Is this a repair to an existing well: [yes or [allo with I5A NCAC 02C.0100 or 15A 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€121 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-1 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: 80(ft.) 24a. For All Wells: Submit this fonn within 30 days of completion of well For multiple wells list all depths ifdifferent(example-3 a200'and 2@100') construction to the following: 10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit, /(water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617 11.Borehole diameter: 8 (in.) 24b. For Infection Wells: In addition to sending the form to the address in 24a Mud Rotary above, also submit one copy of this form within 30 days of completion of well u o 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 Suunly& 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: HTH Amount: 3 0�0 at 1 Og completion of well construction to the county health department of the county where constructed. Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016 _ _Print Form- WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: 1.Well Contractor Information: 7 Sean Cropsey 14.WATER ZONES Well Contractor Name ?} FROM TO DESCRIPTION 160f` 180ft- andst one 2485-A NC Well Contractor Certification Number yY X j OUTER CASING for multi-cased wells OR LINER if a lieable Applied Resource Management q TO DIAMETER THICKNESS MATERIAL rr`r r��$1rd.r ft. 55ft. Bin. SCh 40 PVC Company Name �1t1a�11'`et Ott >,�t�011 (y��y1i 16.INNER CASING OR TUBING(geothermal closed-loa 2.Well Construction Permit#: EHWP-00361-202V FROM TO DIAMETER THICKNESS MATERIAL List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) 0 ft. 160ft- 4 rn' SCh 40 PVC 3.Well Use(check well use): ft. ft. in. Water Supply Well: 17.SCREEN FROM TO DIAMETER, SLOT SIZE THICKNESS MATERIAL J Agricultural [3Municipal/Public 0160f' 180ft• 4 in' 20 Slot SCh 40 PVC :)Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. Industrial/Commercial h!Residential Water Supply(shared) 18.GROUT _;Irri ation FROM TO AATERIAL EMPLACEMENT METHOD&AMOUNT Non-Water Supply Well: ft. 40 ft* Bentonite 24 bags _!Monitoring--- -- Recovery Injection Well: ft. ft. _l Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD J Aquifer Test []Stormwater Drainage 155 ft. 180 ft. #2 Poured Experimental Technology [Subsidence Control ft. ft. -1 Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary) -11 Geothermal(Heating/Cooling Return) _1 Other(explain under 421 Remarks) FROM " DESCRIPTION color,hardness soil/rock type,grain size etc. 0 ft. 20 ft. Clay (orange) 4.Date Well(s)Completed:04/21/2021 Well ID# 20ft- 30 ft- Grey Clay 5a.Well Location: 30 ft- 40 ft- Mud Sand Irena Kohler 40 ft- 55 ft- Clay sand shells Facility/Owner Name Facility lD4(ifapplicable) 551 135ft' Limestone 95 Woodland Tr. Hampstead, NC 28443 135ft• 140 ft. Sand shells Physical Address,City,and Zip 140ft 160' Dark clay Pender 3283-61-9026_0000 21.REMARKS County Parcel Identification No.(PIN) 160-180 Sandstone 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (ifwell field,one[at/long is sufficient) 22.Certification: 34 22 42 N 77 43 2 W 04/22/2021 6.Is(are)the well(s)IaPermanent or Temporary Signature of Certified We Contr r Date By signing this form,I hereby cenfv that the wells)was(were)constructed in accordance 7.Is this a repair to an existing well: 13Yes or ONo with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a If ihis 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 tinder 421 remarks section or on the hack 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 1 GW-1 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: 180(ft.) 24a. For All Wells: Submit this form within 30 days of completion of well For multiple wells list all depths if different(example-3@200'and 1@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: 8 (in.) 24b. For Infection Wells: In addition to sending the form to the address in 24a above, also submit one copy of this form within 30 days of completion of well 12.Well construction method: Mud 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& 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: HTH Amount: 3% at 1 0g completion of well construction to the county health department of the county where constructed. Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016