GW1-2022-01636_Well Construction - GW1_20220203

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Sean Cropsey 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
263ft 283 ft Sandstone (Pee Dee)
2485-A ft ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
Applied Resource Management FROM TO DIAMETER THICKNESS MATERIAL
0 ft 120 ft 6 in. SCh 40 PVC
Company Name
16.INNER CASING OR TUBING eother al 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 ft. 263 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
Agricultural []Municipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) [:)Residential Water Supply(single) 263ft' 283 ft 4 1°' 10 SCh 40 PVC
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft- Bentonite chips Poured
Monitoring ORecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge 0 Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery [:)Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test QlStormwaterDrainage 255ft. 283 ft. #2Gravel Poured
Experimental Technology [:)Subsidence Control ft. ft.
Geothermal(Closed Loop) QlTraeer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soil/rock e, rain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
0 ft. 20 ft. Clay and shells
4.Date Well(s)Completed: 10-19-2021 Well ID# 20 ft. 40 ft. Sand,Shells,Broken Rock
40 ft ft. Limestone
Sa.Well Location: 120
Eileen Rice 120l" 160 ft. Limestone
Facility/Owner Name Facility ID#(if applicable) 160 IL 240 ft, Gray clay,mud and rock
54 Ballast Point Road Hampstead, NC 28443 240ft• 260 ft- Dark mud and sand
Physical Address,City,and Zip 260 ft. 283 ft. Sandstone
Pender 4224-24-3602-0000 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:
N W '!y"4t, 11/24/2021
6.Is(are)the well(s)wPermanent or [3Temporary Signature of Certified Well Contra6t6r Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or ®No with 15A NCAC 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 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: 283 (ft-) 24a. For All Wells: Submit this form 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: 30 (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" - 6"(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 G P M Method of test: Air Lift 24c.For Water Supply&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