GW1-2021-02443_Well Construction - GW1_20210805

C Print rorm
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Don Cummings 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
2412-A fL ft.
NC Well Contractor Certification Number 15.OUTER CASING for mulfi-casedfwells OR LINER if a licable
Applied Resource Management FROM TU DIAMETER THICKNESS MATERIAL
Oft. 35ft. 8 io• Sch 40 1 PVC
Company Name
OSWPWP-21-0082 16.INNER CASING OR TUBING(geothermal closed-too
2.Well Construction Permit 4: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIC,County,Stale,Variance,etc.) oft. 115 ft. 4 in. Sch 80 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
pp y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
-1 Agricultural []Municipal/Public 115ft• 130ft• 4in• 010 SCh 40 PVC
( Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industrial/Commercial E3Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO DATERIAL EMPLACEMENT METHOD&AMOUNT
Non-wa er Supplerell: - _ - - O fc- 65-ft. -Bentonite chips Poured - -
Monitoring DRecovety 105ft- 110fr• Bentonite chips Poured
Injection Well: ft. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑-1 Aquifer Storage and Recovery Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
_ Aquifer Test nStormwater Drainage 110 ft. 130 ft. #2 Gravel Poured
I Experimental Technology 1 'Subsidence Control ft. ft.
)Geothermal(Closed Loop) nTracer 20.DRILLING LOG attach additional sheets if necessary)
_1 Geothermal(Heating/Cooling Return) Other(explain under 421 Remarks) FROM To DEscRIITION rotor,hardness soil/rocktype, rain size,etc.
Oft. gft. sand
4.Date Well(s)Completed:07/12/2021 Well ID# 9 ft. 32ft• clay
5a.Well Location: 32ft• 621• limestone
Lisa Underwood 62 ft. 112 ft. clay with shell rock layers
Facility/Owner Name Facility 1D4(if applicable) 1 12fr• 135 ft. sandstone
7016 Meadowview Ave. Wilmington 28411 ft. ft. r�
Physical Address,City,and Zip ft. ft.
New Hanover R03511-001-001-000 21.REMARKS s
County Parcel Identification No.(PiN)
oc�'• `N
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat4ong is sufficient) 22.Certification:
341738.27N 77 50 17.95 w �eM, Q, 07/27/2021
- -- Signature of Certified Well Con or -- -Date---------
6.Is(are)the well(s).�l Permanent or �ITemporary --
liv signing this form,I hereby cerlifi that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: nYes or ONo 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 lhis record has been provided to the well owner.
repair ender r21 remarks section or on the hack 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 i GW-I 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: 130(ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list al/depths ifdifferem(example-3@200'and 2@100') construction to the following:
4
10.Static water level below top of casing: 35 (ft.) Division of Water Resoulrees,Information Processing Unit,
lfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 121e 18et (in.) 24b.For Injection 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
u
12.Well construction method: 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 Suvvly& 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.
I
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016