GW1-2021-01824_Well Construction - GW1_20210927

�wn
WELL CONSTRUCTION RE •RD ,
NORTH CAROLINA
EnWronmental Quullty
•rm GW-1 Well Constructon Electronic •
North Carolina Department of Environmental Quality
April 1,2021
Submission ID#
G W 1-2021-01824
Are you submitting a printed form?* r Yes
r No
CONTACT INFORMATION
.........................................................................................................................
Contact Name* Email Address*
Alyce Bean [e-mail]
Is this a revision to the form you have previously submitted?
r Yes r No
WELL CONSTRUCTION INFORMATION
1.Who is installing these wells?*
r Owner r Well Contractor
1.Well Contractor Information:
Certiticate# Cert Level First Name Last Name Company Name
2412 A DONALD CUMMINGS,JR. APPLIED RESOURCE MANAGEMENT
2.Well Construction Permit#:
List all applicable well construction permits(i.e.Monitoring Wells,UIC,County,CCPCUA,etc.)
What type of well is this?* r Injection Well r Non-Water Supply Well
r Water Supply Well(includes irrigation wells)
3. Non-Water Supply Well* r Monitoring
r Recovery
4. Date well was completed and ID#
Date Well Completed* Well ID# Well Yield
9/2/2021 (gallons per minute)"
5.Well Location

Facility/Owner Name
Route Tampa LLC Facility ID#
(Required) (If applicable)
County* Parcel Identification No.(PIN)
New Hanover 04712-005-003-000
Physical Address* Street Address
909/923 North 3rd Street
Address Line 2
City State/Province/Region
Wilmington NC
Postal/ZZp Code Country
28401-3409 US
Latitude* 34.2459220000 Longitude' 7.9475500000
Decimal degrees Decimal degrees
6. Is(are)the well(s):* r Permanent r Temporary
7. Is this a repair to an existing well:* r Yes F No
If this is a repair,fill out known well construction information and e)plain the nature of the
repair under#21 remarks section or on the back of this form.
For multiple Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction,only 1 GWA is needed.
8a. Indicate TOTAL NUMBER of wells drilled:
9.Total well depth below land surface:(ft.)
22 9a.What is the depth of the casing from ground
Formultiplewells Iistall depths if different surface?
(example-3 a200'and 2@100') in feet
10.Static water level below top of casing:(ft.) 11. Borehole diameter:
12.57 8 1/4
If water level is above casing,use"+" in inches
12.Well construction method:
r Auger r Air Rotary r Cable Tool
r Direct Push r Mud Rotary r Rotosonic
r Other
14.WATER BEARING/FRACTURE ZONES
From To Description
in feet in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
From To Diameter Thickness Material
in feet in feet in inches
17.SCREEN
From To Diameter Thickness Material

2.00 22.00 2.00 Sch 40 PVC
in feet in feet in inches
18.GROUT
From To Material Emplacment Method &Amount
1.00 10.00 bentonite poured
in feet in feet
0.20 1.00 concrete poured
in feet in feet
19.SAND/GRAVEL PACK(if applicable)
From To Material Emplacment Method
10.00 22.00 well gravel poured
in feet in feet
20.DRILLING LOG
From To Description (color, hardness,soil/rock type,grain size,etc.)
in feet in feet See Attached
21.Remarks
22.Site diagram or additional well details:
You mayupload additional well construction information here.
Soil Boring logs.doc 3.pdf 12.07KB
pdf only
CERTIFICATION INFORMATION
...................................................................................................................................................
* By signing this form, I hereby certify that the well(s)was(were)constructed in accordance with 15A NCAC 02C
.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy of this record has been provided to
the well owner.
23.Certification*
Signature of Certified Well Contractor
Submittal Date 9/27/2021

909/923 N. 3rd STREET
WILMINGTON, NC
MWAOC-4

Drilled by : Applied Resource Management
Logged by: J. Zuncich
Date: 9/2/21
Depth
(ft.)
Description Water
Content
Blow
Count
2 - 4 Brownish orange, fine to medium grained sands-fill material.
No obvious hydrocarbon odors.
Low Grab

5 - 7 Brown to orange, medium grained sands-fill material changing
to tan beige, very fine to fine grained sand. No obvious
hydrocarbon odors.
Low HP

10 - 12 Light to medium gray, very fine to fine grained sand. No
obvious hydrocarbon odors.
Low to
moist
HP

15 - 17 Dark brown, fine to medium grained sands with minor peat
lense. No obvious hydrocarbon odors.
Moderate
to High
HP

20 - 22 Brown to gray, fine to medium grained sands. No obvious
hydrocarbon odors.
High HP

HP = Hydraulic Push