GW1-2021-05996_Well Construction - GW1_20211008

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.well Contractor Information:
Sean Cropsey 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
2485-A 210 ft. 235ft- sandstone
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a lieable
Applied Resource Management FROM TO DIAMETER THICKNESS MATERIAL
0 ft 200 ft. 4 in SCh 40 PVC
Company Name
EHWP-00553-2021 16.INNER CASING ORTUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER TIHCKNTSs I MATERIAL
List all applicable well construction permits(i.e. UIC,County,State, Variance,etc.) 195 ft. 215 ft. 2 in. SCh 40 PVC.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
J Agricultural [3Municipal/Public 215fL 235ft- 2 in.: 20 SCh 40 PVC
])Geothermal(Heating/Cooling Supply) BResidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
_I Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Bentonite Tremmie-22 bags
_I Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
J Aquifer Recharge OGroundwater Remediation 19.SAND/GRAVEL PACK if applicable)
J Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
J Aquifer Test ®Stormwater Drainage ft. ft.
J Experimental Technology nSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
-1 Geothermal(Heating/Cooling Return) _ Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness,soil/rock type rain size etc.
0 ft. 1Oft. clay
4.Date Wells)Completed: 09/23/2021 well ID# 10 ft. 20ft• sand& clay
Sa.Well Location:
20 ft. 60ft• sand &shells
Christopher Dodds 60 ft. 70 ft shells&clay Q \�
Facility/Owner Name Facility ID#(ifapplicable) 70 ft. 200ft. limestone
1925 Country Club Dr., Hampstead 28443 200ft- 210ft• salt&pepper rock&sand o
Physical Address,City,and Zip 210 ft. 235rL sandstone&mud
Pender 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/tong is sufficient) 22.Certification:
34 23 37 N 77 39 28 w 09/23/2021
6.Is are the wells I Permanent or-OTemporary Signature of Certified Will Con for Date
By signing this form,I hereby certfv that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DJ Yes or [a No with 15A ArCAC 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#21 remarks section or on the hack of this farm.
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-1 is needed. Indicate TOTAL NUMBER of%yells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 235(ft-) 24a. For All Wells: Submit this fonn 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: 22 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+^ 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 followmg:
(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) 35 Method of test-. Air Lift 24c. For Water Supply& 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: 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