GW1-2021-06961_Well Construction - GW1_20210505

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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