GW1-2021-03547_Well Construction - GW1_20210607

I Prrnt Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Sean Cropsey 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2485-A 35 ft. 57"- Rock& Sand
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR'LINER if a licable
Applied Resource Management RINNER
TO DIAMETER THICKNESS MATERIAL
ft. in.Company NameCASING OR TUBING eotbermal closed-too2.Well Construction Permit 4: TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits•(i.e.UIC,County,State,Variance,etc.) 37 ft- 4 m- Sch 40 PVC
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public 37ft 57 ft- 4'n' 10 Sch 40 PVC
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) f[. ft. in.
Industrial/Commercial OResidential Water Supply(shared) iS.GROUT
_ lift ation FROM TO MATERIAL- .EMPLACEMENT METHOD&•AMOUNT
Non-Water Supply Well: Oft 371L Bentonite Tremmie- 13 bags
_ Monitoring DlRecovery ft. ft.
Injection Well: ft. ft.I._)Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E)Stormwater Drainage 30' 57 ft- #2 Gravel Poured
Experimental Technology Subsidence Control ft. ft.
:]]Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under 421 Remarks) FROM TO DESCRH'TION color,hardness soil/rock type,grain size,etc.
0 ft. 20ft. clay
4.Date Well(s)Completed: 05/1 3/2021 Well ID# 20f1• 30f- shells&Sand
5a.Well Location: 30ft• 35ft shells:;
David Shepherd 35ft- 50ft rock&sands
Facility/Owner Name Facility ID#(if applicable) 50 ft. 57 ft. sand & clay
3931 NC 133 Rocky Point, NC 28457 ft ft
Physical Address,City,and Zip ft. ft.
Pender 3214-64-3099-0000 21.REMARKS 2071
County Parcel Identification No.(PIN) r t� CcesslRg tJlll�
._,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: D'vl��R Sect cn
(if well field,one lat/Iong is stifficient) 22.Certification:
34 24 56 N 77 57 6 W 'Is�,� 05/14/2021
6.Is(are)the well(s) Permanent _or Temporary Signature of Certified\ ell Con ctor Date
13v signing this farm,I hereby cerl fv that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [ Yes or 1/J No with 15A 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#11 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 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: 57(ft.) 24a. For All Wells: Submit this form Within 30 days of completion of well
For multiple wells list all depths ifdii fereni(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 15 (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 lniection Wells: In addition to sending the form to the address in 24a
above, also submit one cop),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 Suimly&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: Amount: 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