GW1-2021-04607_Well Construction - GW1_20210510

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: I+�
Sean Cropsey 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2485-A P�1A`f 1 2021 70ft• 11Oft• Limestone
NC Well Contractor Certification Number OrnCPOSSlllg
nit ft. ft.
J`l.n 3oiB'{11[ �+-� 15.OUTER CASING for multi-cased'wells OR-LINER if a licable
Applied Resource ManagemenYr'^ U111 i1 SELt,�11 FROM TO DIAMETER THICKNESS DATERIAL
ft• 78ft• 4 In SCh 40 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit 4: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
J Agricultural C]MunicipaVPublic 0 fL fL in.
:]Geothermal(Heating/Cooling Supply) I_J Residential Water Supply(single) ft. ft. in.
IndustrialiCommercial (_l Residential Water Supply(shared) 18.GROUT
V,Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water supply Well: 0 ft• 78 ft• Bento'nite 30 Bags
j Monitoring ❑Recovery
- Injection-Well: - --- -- -
ft R.
Aquifer Recharge n
i Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)__
Aquifer Storage and Recovery L Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
_l Aquifer Test [3Stormwater Drainage
ft. ft.
:]Experimental Technology nSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
[]Geothermal(Heating/Cooling Return) I Other(explain under 421 Remarks) FROM TO DESCRIPTION color,hardness soil/rock type,grain size,etc.
0 ft. 20 ft. Clay & Shells
4.Date Well(s)Completed: 05/06/2021 Well ID# 20ft. 40ft. Shells& Sand
5a.Well Location: 40ft• 70ft• Clay dark&Shells
Applied Resource Management 70ft• 110ft• Limestone
Facility/Owner Name Facility ID#(if applicable) ft. ft.
257 Transfer Station Rd. Hampstead, NC 28443 ft. ft.
Physical Address,City,and Zip fL ft.
Pender 4203-27-3881-0000 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
34 23 49N 77 40 3 w �'a� � 05/10/2021
6.Is(are)the well JoPermanent or [3 Temporary Signature of Certified Veil Con ctor Date
1v signing this form, I hereby certifv that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or ONo with 15A NCAC 01C.0100 or I5A NCAC 02C.0100 Well Construction Standards and that a
If this is a repair,fill out known well cons/ruction information and explain the nature of the ropy 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: 110(ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if difterem(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 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
Mud Rota above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: ry 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 Supply& Injection 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: 3% at 10g 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