GW1-2022-05795_Well Construction - GW1_20220615

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: Print Form
1.Well Contractor Information: ����' �
Sean Cropsey 14.WATER ZONES
Well Contractor Name a �Orl� FROM TO DESCRIPTION
2485 -A JUN 13
L 35 55 Sand and Limestone
`n' ft. ft.
NC Well Contractor Certification Number ®EQ/D V`t B 15.OUTER CASING for multi cased wells OR LINER if a licable
ARM r tralOffice FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 fL 42 It. 8 1O1 SCH 40 1 PVC
16.INNER CASING OR TUBING eothermal closed-loon)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL.
List all applicable well construction permits(i.e.U1C,County,State,variance,etc.) +1 ft. 35 ft 4 — SCH 40 T PVC
3.Well Use(check well use): ft. ft in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public 35 It. 55 fL 4 in. 10 SCH 40 PVC
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irri ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 It' 28 rL Bentonite Chips Poured 12 ba s
- Monitoring--- - —EjRecovery------- - ----- —- -ft. - ft - - — ---— -- --
Injection Well: ft. ft.Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
Aquifer Storage and Recovery [3 Salinity Barrier FROM TO I MATERIAL I EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage 2$
fa 55 ft. #2 Gravel Poured
Experimental Technology Subsidence Control ft. ft
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessa
Geothermal(Heating/Cooling Return) r3Othcr(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soil/rock type,grain size,etc.
0 ft 10 f` Clay
4.Date Well(s)Completed: 5/26/2022 Well ID# 10 fL 20 It. Sand
5a.Well Location: 20 ft. 30 ft. Grey Clay with Shells
Antonio Reyes 30 ft- 40 1" Shells and Sand
Facility/Owner Name Facility M#(ifapplicable) 40 It. 45 ft. Limestone Open Hol .--& I Camj
407 Rutledge Drive Wilmington 28412 45 ft" 55 It. Limestone
Physical Address,City,and Zip ft. ft. re Q2 C-�
i
New Hanover R06506-003-004-000 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:
340 11' 18" N 77e 56' 15" W �
05/26/2022
6.Is(are)the well(s)JIPermanent or Temporary Signature of Certified Well 06ntraclr
Date
By signing this form,I hereby certijy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 13yes or MNo with 15A NC4C 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
f 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 I 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: 55 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 20 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater 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
(Le Well construction method: Mud ROta rV(Le.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: Air Lift 24c.For Water Sunnly&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: 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