GW1-2022-06004_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 DESCRrPTII N
2485-A 200ft. 220 ", Sandy Rock and shells
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable)
FROM TO DIAMETER THICKNESS MATERIAL
Applied Resource Management
1 ft. 203 It. 4 SCh 40 PVC
Company Name
227071-1 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#' FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County.State, Variance,etc.) 190rt• 200 ft.
2 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 [3Municipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) 200 ft. 220 ft- 2 in. 10 SCh 40 PVC
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft- Bentonite Poured 14 Bags
Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVELPACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 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. 20 ft• Clay
4.Date Well(s)Completed: 10/21/2021 Well ID# 20 ft. 40 ft- Sandhills
5a.Well Location: 40 ft. 60 ft. Shells to limestone
Eddie Cameron Construction,Inc 60 fr. 140 ft, Limestone
Facility/Owner Name Facility ID#(ifapplicable) 140 ft. 200 ft Dark Mud _
1909 Paulette Road, Morehead City 200 ft- 220 ft. Sandy,shelly 0
Physical Address,City,and Zip ft. ft.
Carteret 638605283940000 21.REMARKS
County Parcel Identification No.(PIN)
b(:j}';�,' •�i4tr
5b.Latitude and longitude in de rees/minutes/seconds or decimal degrees: I'.r?N' '�4t mr � " n,'I V^r
g g g uvu IPC i i sv n-vavuu'�r evt�
(ifwell field,one lat/long is sufficient) 22.Certification:
34 44 32 N 76 43 42 W 11/1/2021
6.Is(are)the well(s)imlPermanent or OTemporary Signature of Certified Well Contrilctor Date
By signing this form,I hereby certi,that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: nYes or ONo with ISA 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 ropy 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 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: 220 (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: 15(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
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) 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-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016