GW1-2022-01640_Well Construction - GW1_20220203

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 220ft• 245 ft. limestone gray
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
Applied Resource Management PC FROM TO DIAMETER THICKNESS MATERIAL
4 ft 225ft- 4 in Sch 40 PVC
Company Name
16.INNER CASING OR TUBING eother at closed-loop)
2.Well Construction Permit#: 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
Agricultural []Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
atlOri FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
�Irn
on-Water Supply Well: 0 ft. 20 ft- bentonite chips Poured
Monitoring ORecovery ft. ft.
Injection Well: ft. ft.
PAquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
DAquifer Storage and Recovery [:)Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test 01 Stormwater Drainage ft. ft.
Experimental Technology [:)Subsidence Control ft. ft.
Geothermal(Closed Loop) QlTracer 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. 30 ft. Clay
4.Date Well(s)Completed. 10/20/2021 Well ID# 30 ft. 60 ft. sand &shells
5a.Well Location: 60 ft. too ft. Gray Clay
Jonathan Birkett 140ft. 190ft. Sandy Clay and Mud Rock
Facility/Owner Name Facility ID#(if applicable) 190ft. 220ft. Shells and Sand, Yellow Coquinn
179 Turnpike Road Newport, NC 28570 220 ft. 245 ft. Gray Limestone
Physical Address,City,and Zip ft. ft.
Carteret 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:
340 49' 14" N 76° 12' 6" w '5'aa.'y �� 10/20/2021
6.Is(are)the well(s)jZi Permanent or [3Temporary Signature of Certified Well Contr for 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: 245 (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: 18 (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 Iniection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form 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) 25 Method of test: 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: Amount: 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