GW1-2021-05321_Well Construction - GW1_20211001

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
� t
Sean Cropsey �� l 7�S 14.WATER ZONES U
FROM I TO DESCRIPTION
Well Contractor Name
20 ft- 40l" medium yellow sand
2485-A O TO ��` 40 fI, 41 f- fine grey sand
NC Well Contractor Certification Number (\C
15.OUTER CASING for multi-casTEzells OR LINER if i>i 7icable
Applied Resource Management ploy y�0 FROM TD DIAMETER THII::. s MATERIAL
ft, ft.
Company Name i�f�C �.� J 16•INNER CASING OR TUBING eother al closed-loo
2.Well Construction Permit#: EHWP-386-20 1 FROM To DIAMETER THICIrn•ESS MATERIAL
List all applicable well construction permits(i.e. UIC,County,State, Variance,etc.) 0 ft. 31 ft. 4 in- SCh 40 PVC
3.Well Use(check well use): fL ft. in.
17.SCREEN
Water Supply Well: FROM To DIAMETER SLOT SIZE THICKNESS MATERIAL
J Agricultural OMunicipal/Public 31 ft 51 ft. 4 in- 20 slot SCh 40 PVC
Geothermal(Heating/Cooling Supply) D Residential Water Supply(single) ft. ft. in.
i Industrial/Commercial [�Residential Water Supply(shared) IS.GROUT
_!Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 27 ft- hole plug 13 bags
J Monitoring Recovery ft. ft.
Injection Well: ft. ft.
J Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery ❑ Salinity Barrier FROM To I MATERIAL EMPLACEMENT METHOD
J Aquifer Test OStormwater Drainage 30 ft. 51 ft. #2 Gravel poured 15 bags
Experimental Technology Subsidence Control ft. ft.
J Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
J Geothermal(Heating/Cooling Return) _I Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness soil/rock type,grain size etc.
0 ft. 10 ft. clay
4.Date Well(s)Completed: 09/14/2021 Well ID# 10ft• 20ft• wood &shells
5a.Well Location: 20ft• 40ft• yellow!mud sand
Mike Heath 40 ft' 51 ft. grey sand
Facility/Owner Name Facility ID#(if applicable) ft. ft.
514 Complex Rd. Rocky Point 28457 ft. ft.
Physical Address,City,and Zip ft. ft.
Pender 3223-72-5911 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22.Certification:
34 23 8 N 77 54 49 w
I "4z' ,Ash 09/27/2021
6.Is(are)the well(s)oPermanent or OTemporary Signature of Certified MKII Con for Date
By signing this form,I hereby certifv that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: EJ Yes or RNo with ISA NCAC 01C.0100 or hA 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 921 remarks section or on the back of this firm.
23.Site diagram or additional well details:
S.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: 51 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(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,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8 (in.) 24b. For Iniection 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
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 25 GPM Method of test: Air Lift 24c. For Water Suooly& Iniection 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: 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