GW1-2022-05772_Well Construction - GW1_20220614

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: C V
Sean Cropsey 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2485 -A , �� 100 ft 122 Limestone
4�I� ft. ft
NC Well Contractor Certification Number 4
®�a�® `� 15.OUTER CASING for multi cased wells OR LINER if 209
licable
ARM ��� FROM TO DIAMETER THICKNESS MATERIAL
Company Name +1 fc I 102 4 'n I SCH 401 PVC
16.INNER CASING OR TUBING eothermal dosed-loon)
2.Well Construction Permit#: OSWPWP - 22 - 0054 FROM TO DIAMETER I THICKNESS I 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 SLOTSIZE THICKNESS MATERIAL
Agricultural �MunicipaUPublic 102 ft 122 ft-
JD 4 '°' 20 SCH 40 PVC
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft in
Industrial/Commercial Residential Water Supply(shared) 19.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft ft* Bentonite Chips Poured 30 Bags
- - Monitoring-- - -- - - -ORecovery- - —- -- - —ft- -ft--- - ---- -- - --
Injection Well:
Aquifer RechargeGroundwater Remediation ft ft
Aquifer Storage and Recovery Salinity Barrier19.SAND/GRAVEL PACK if alicablelei FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13StormwaterDrainage 100 ft 122 ft #2 Poured 15 Bags
Experimental Technology [Subsidence Control ft ft
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) []Other(explain under#21 Remarks) FROM TO DESCRIMON color,hardness soil/rack type,grain sin etc.
0 ft 15 ft Sand _
4.Date Well(s)Completed:05/23/2022 well ID# 15 ft 30 ft Clay a
Sa.Well Location: 30 ft 60 ft Sand o i� I
Jacob Stockton 60 ft 75 ft Clav Lr, 5
Facility/Owner Name Facility ID#(if applicable) 75 ft 85 ft Shells and Sand '"1 eq 0
321 Friendly Lane Wilmington NC 28409 85 ft 122 ft Limestone
Physical Address,City,and Zip ft ft
New Hanover R07200-008-031-000 21.RENIARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sufficient) 22.Certification:
340 8' 54" N 770 51' 46" W 'na'M' 04/24/2022
6.Is(are)the well(s)fflPermanent or DTemporary Signature of Certified Well Co tractor 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: I]Yes or EJNo 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: 122 ft.
( ) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tf 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 (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
(ic Well construction method: Mud Rotary.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 Method of test: Airlift 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 Ib 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