GW1-2021-04354_Well Construction - GW1_20210429

Print Form.
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Sean Cropsey 14.WATER ZONES
Well Contractor Name
FROM TO DESCRIPTION
2485-A �� Q'L� 60 ft. 93rt Limestone
9 ti yr ft. ft.
NC Well Contractor Certification Number AQ� es5�n9 15.OUTER CASING for multi cased wells OR LINER it a 7icable
Applied Resource Management, PG Q�°�'�io� FROM TO DIAMETER THICKNESS MATERIAL
Company Name `fi3\i ^, ft. 5ft- $in• SCh 40 PVC
!� V 16.INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit#: EHWP-00U-2 1 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) oft. 73 ft- 4 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 ®MunicipaUPublic 0 73ft- 93rL 4in• 20 Sch 40 PVC
J Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fa ft in.
:]Industrial/Commercial Residential Water Supply(shared) 18.GROUT
l Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. 20ft. Bentonite Tremmie
:]Monitoring IO'Recovery ft. ft.
-Injection_Well:, - ft-` ft. --- --_ - - _
-J Aquifer Recharge DGroundwater Remediation 19.SAND/GRAVEL PACK ifs licable
Aquifer Storage and Recovery (-I Salinity Barrier FROM I TO MATERIAL T EMPLACEMENT METHOD
J Aquifer Test ®Stormwater Drainage 70ft. 93ft. #2 IPoured
Experimental Technology !3Subsidence Control ft. ft.
_I Geothermal(Closed Loop) []Tracer 20.DRILLING LOG attach additional sheets ifnecessa
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soil/rock e,grain size etc.
Oft. 1Or- Clay
4.Date Well(s)Completed:04/07/2021 Well ID# 1Oft. 30ft• Sand to gray clay
59.Well Location: 30 ft- 50ft• Gray Clay, Shells
Salvatore Ceraldi 50ft• 60ft- Coarse'Gravel-to Limestone
Facility/Owner Name Facility ID#(ifapplicable) 60ft. 100 ft' Limestone
Lot 4 Pinnacle Pkwy. Hampstead, NC 28443 ft. ft.
Physical Address,City,and Zip ft. ft.
Pender 3294-88-5704-0000 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
34 25 33 N 77 40 44 W 04/09/2021
6.Is(are)the well(s)aPermanent or OTemporary Signature of Certified ell Cot clot, Date
By signing this form,I hereby certifv that,the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or DNo
with ISA NCAC 02C.0100 or/SA 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 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: 93(ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 10 (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above caring,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
n
11.Borehole diameter: 8 (in.) 24b. For Iniection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this forth within 30 days of completion of well
12.Well construction method Mud Rotary 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) Method of test: 24c.For Water Suonly&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: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016