GW1-2021-05593_Well Construction - GW1_20211015

�� Pr•int Form �_�
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Sean Cropsey 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 100 fL 122 ft- Limestone
2485-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-eased wells OR LINER if a lieable
Applied Resource Management FROM TO DIAMETER TRICKINESSI MATERIAL
Company Name Oft' I 48ft• 8in Sch40 pvc
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,State, Variance,etc.) #1 fit. 102 fL 4 in• seh 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 OMunicipal/Public 102ft- 122 fL 4 in, 20 Slot Sch 40 pVC
_J Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft. ft. in.
J Industrial/Commercial Residential Water Supply(shared) 18.GROUT
,1rri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. bentonite poured
_ Monitoring ORecovery k. ft.
Injection Well: ft. ft.
:)Aquifer Recharge �GroundwaterRemediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACErsfENT METHOD
J Aquifer Test OStormwater Drainage95fL 122ft #2 poured
Experimental Technology Subsidence Control ft. ft.
BGeothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) 1 Other(explain under 421 Remarks) FROMI TO DESCRIPTION color,hardness soil/rocktype,grain size etc.
0 ft. 20 ft- clay
4.Date Well(s)Completed: 09/28/2021 well ID# 20 ft- 30 ft. clay (gray) -some sand
Sa.Well Location:
30 ft- 40 fit- gray Y cla -
mud &fine sand
Comet Builders 40 ft- 48 ft limestone broken white
Facility/Owner Name Facility lD4(ifapplicable) 48fL 122ft• limestone gray
ft. ft.
Physical Address,City, 4
Y tY,and Zip ft. ft.
Craven 8-209 -25000 21.REMARKS OCT 2021
County Parcel Identification No.(PIN) J
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: "sir aS t
(ifwell field,one fat/long is sufficient) 22.Certification: 6 tl.�t I i Mt NI P,Sv"t' 'Oi1
� ,
35 7 55 N 77 7 32 w .5,� 10/04/2021
6.Is(are)the well(s)ElPermanent or OTemporary Signature of Certified Well Co ctor Date
Ikv signing this form,I herebv certfv that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or [allo with I5A 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 921 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: 122 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierew(example-3@200'and 2@.100') construction to the following:
10.Static water level below top of casing: 30 (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
.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.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) 50 Method of test: Air Lift 24c. For Water Suomly& 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 Ib 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