GW1-2021-06278_Well Construction - GW1_20210915

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Sean Cropsey 14.WATER ZONES
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DESCRIPTION
Well Contractor Name 1 �'vy• V50IL limestone sand limestone
2485-A ��p Yy� oees��g ft j
NC Well Contractor Certification Number `tQ �Q�
Applied Resource Managemen�ct�����p�^1RSg FROM 15.OUTER CASINGfor multi-cased wells OH INERCKNE ifa livable
FROM TO DIAMETER THICKNESS MATERIAL
Oft 55ft• 12 in- I Sch 40 PVC
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Slate, Variance,etc.) 0 ft. 130ft• 6 in. 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 130 fL 150 ft- 6 in. 20 Sch 40 PVC
:]Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft• ft. in.
_]Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Vjllrrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
-- Non-WaterSupply Well: - -- — 0 ft. 30 ft- bentonite_s_—tremmie
_I Monitoring Recovery ft. ft.
Injection Well: ft. ft.
_1 Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
I Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL EMPLACEl%=METHOD
J Aquifer Test OStormwater Drainage 115 ft• 150 ft• #2 gravel Poured
Experimental Technology OSubsidence Control
_1 Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets ifnecessa
_l Geothermal(Heating/Cooling RetReturn) Other(explain under 421 Remarks FROM TO DESCRIPTIONcolor,hardness soil/rock type,grain size etc.) 0 ft. 10 ft.
sand clay
4.Date Well(s)Completed: 08/20/21 Well ID# 10 ft. 30 ft. clay
Sa.Well Location: 30 ft. 40 ft- clay sand layers
Belvedere Property Management 40 ft. 55 ft- sand&ishells
Facility/Owner Name Facility ID#(if applicable) 55 ft. 70 ft. limestone hard sandy
9149 Orton Rd. SE Winnabow, 28479 70 ft, 130 ft- sand limestone layers with mud
Physical Address,City,and Zip 130 ft. 150 ft. limestone to sandy limestone
Brunswick 311100749747 21•REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one latAong is sufficient) 22.Certification:
344 10 N 77 58 35 N :y� 08/31/2021
6.Is(are)the-well(s)OPermanent or OTemporary Signature of Certified ell Con ctor Date
,6y signing this form,I hereby cerlifv lha't the well(s)was(were)cbmirucied in accordance —
7.Is this a repair to an existing well: E]Yes or ONo with 15A A'CAC 02C.0100 or 15A NCAC 02C.0200 I'ell 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#21 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: 150(ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ijdierent(example-3@200'mid 2@100') construction to the following:
10.Static water level below top of casing: 25 (ft.) Division of Water Resources,Information Processing Unit,
/fwater level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 9 7/8 (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.Huger,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) 60 Method of test: Air Lift 24c. For Water Supply& Iniection Wells: In addition to sending the form to
the address(es) above, also submitl one copy of this form within 30 days of
13b.Disinfection type: HtH Amount: 1 lb 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