GW1-2022-06673_Well Construction - GW1_20220708

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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 DESCRIPTION
90 ft. 120 f'' Limestone
2485 - A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
ARM FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 100 ft. 4 : in. SCH 40 PVC
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.1/1C,Comay.State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
industrial/Commercial Residential Water Supply(shared) 18.GROUT
irri atlon FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 20 f`' Bentonite Chips Poured 17 Bags
Monitoring - 13
Recovery ft. ft.
injection Well:
ft, ft.
Aquifer Recharge [I Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. fr.
Experimental Technology 13Subsidence Control ft. ft.
Geothermal(Closed Loop) ®ITracer 20.DRILLING LOG-attach additional sheets if necessary
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness,soil/rock type,grain size,etc.
ft'
20 ft' Clay
05/17/22 Well iD# f" ft.
4.Date Well(s)Completed: 20 6 Sand
5a.Well Location: 60
ft. 85 ft. Clay
Sydes Construction 85ft. f'. Sand and some shells
Facility/Owner Name Facility iD#(ifapplicable) 90 ft. 120 ft. Limestone
TR1 ONSLOW 19 STATESIDE TRACT P3 ft. ft.
�.•.tea q
Physical Address,City,and Zip ft. ft. %!r- It V
Onslow 446000464605 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: �Ln QiYa�
34o 51' 38" N 77° 27' 32" `y,
'��eawl 5/23/2022
6.is(are)the well(s)[IPermanent or OTemporary Signature of Certified Well Co actor Date
By signing this form,I hereby cerlifi,that the well(,)was(were)consinicied in accordance "
7.Is this a repair to an existing well: 13Yes or IgNo with 15A NCAC 02C.0100 or 15A NC'AC 02C.0200 melt Cbnsiruction Standards and that a
/f this is a repair,fit/oul known well construction information and explain the nature of the copy Qf this record has been provided to the well owner.
repair under k21 remarks section or on the hack ofthis 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: 120' (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For nmhiple wells list all depths ifdt(jerem(example-3�200'and 1 r/00') construction to the following:
t
10.Static water level below top of casing: 20 (ft.) Division of Water Resources,information Processing Unit,
lj'waier level is above casing.use" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8" (in.) 24b. For infection 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: Mild 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) 60 gpm Method of test: Air Lift 24c. For Water Sunnly& Infection 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-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016