GW1-2021-06938_Well Construction - GW1_20210505

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Sean Cropsey � 14.WATER ZONES k
Well Contractor Name Y- FROM TO DESCRIPTION
2485-A JIL X 2021 45ft- 61fL Limestone
fL ft
NC Well Contractor Certification Number r,.r r��S;r37 l)tl
15.OUTER CASING for muHi-cased'wells OR LINER if a livable
r li`= ;If.� t'f.�rtifl l� FROM TO DIAMETER THICIINESS MATERIAL
Applied Resource Managern6iif p'vul�
Oft. I 40ft. gin. 40 PVC
Company Name
2021075323 16.INNER CASING OR TUBING etithermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL.
List all applicable well construction permits(i.e.UIC,County,Stale,Variance,etc.) 0 ft. 46 ft- 4ia SCh 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipal/Public 0 46fL 61ft- 4in• 20 Sch 40 PVC
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fL fL in.
Industrial/Commercial Residential Water Supply(shared) IS.GROUT
lrri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ftChips Poured
-!Monitoring_ .Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK if a livable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
J Aquifer Test Stormwater Drainage 45 ft. 61 fL #2 Poured
J Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
I Geothermal(Heating/Cooling Return) 00ther(explain under 421 Remarks) FROM TO DESCRIPTION color,hardness soil/rock t3Te,grain size etc.
0 ft- 10 ft- Clay-orange
4.Date Well(s)Completed:04/20/2021 Well ID# 10 ft. 20 fL Sand med
5a.Well Location: 20 ft. 30 ft- Tan&orange clay
Timothy Wesley Cross General Contracting 30 ` 38 fL Clay-coarse sand
Facility/Owner Name Facility ID#(ifapplicable) 38 ft. 40 ft. Open hole
3965 River Rd. SE Winnabow, NC 28479 40 f' 61 ft- Limsetone gray
Physical Address,City,and Zip ft. ft.
Brunswick 310200890947 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
34.1011861 N 77.9751216 w Sa.�.rrr ' 04/20/2021
6.Is(are)the well(s)oPermanent or OTemporary Signature of Certified VAII Con for Date
By signing this form,I hereby certifv that the well(J)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.0200 Well Construction Standards and that a
1f 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 Ihis 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: 61 (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 2@100') construction to the following:
10.Static water level below top of casing: 12 (ft.) Division of Water Resources,Information Processing Unit,
if water level is above casing,rise"+" 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
12.Well construction method: Mud Rotary above, also submit one copy of this form within 30 days of completion of well
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 Suobly& Iniectioln 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-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016