GW1-2022-05988_Well Construction - GW1_20220617

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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 I DESCRIPTION
2485-A 40 ft. 90 ft- Limestone
fr. ft.
NC Well Contractor Certification Number
15.OUTER CASING far multi-cased wells OR LINTER if a licable
Applied Resource Management FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 47 ft. 8 in- I Sch 40 PVC
16.INNER CASING OR TUBING eother al closed-loop)
2.Well Construction Permit#: FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0 ft. 70ft. 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 E]MunicipaUPublic 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
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 P Poured 20 Bags
Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK ifa licable
3Aquifer Storage and Recovery [ISalinity Barrier FROM TO I MATERIAL I EMPLACEMENT METHOD
Aquifer Test [3 Stormwater Drainage
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 DESCRIPTION color,hardness,soillrock type,grain size,etc.
0 ft. 20 ft, clay
4.Date Well(s)Completed: 10/06/2021 sell ID# 20 ft. 40 1 Sand Shells to Crumbly Rock
Sa.Well Location: 40 It. 90 1" Limestone
Edwin Jones ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. F
6706 Barren Inlet Road Wilmington, NC 28411
ft. ft.
Physical Address,City,and Zip ft. ft. s `
New Hanover R05100-005-001-003 21.REMARKS AA
County Parcel Identification No.(PIN)
lr`:r L`�:'tdiN i I'�rJ t'I'i!J�L J•�l;t'R9 I\
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
34, 15,15 N 77,47,23w 5e a.0, � 10/12/21
6.Is(are)the well(s)QPermanent or Temporary Signature of Certified Well Con&6ctor Date
By signing this fornt,I hereby certifj•that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: EIYes or ✓JNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Nell 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 o(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: 90(ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(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 -4(in.) 24b.For Injection 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) 50 GPM Method of test: Airlifted 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: HTFi 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