GW1-2022-06987_Well Construction - GW1_20220725

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Irvinn Bautista 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
4504-A ft. ft.
NC Well Contractor Certification Number EL ! 15.OUTER CASING for multi-cased wells OR LINER if a licable
A.C. Schultes of Carolina, Inc. iD FRObI TO DIAhIETER THICKNESS MATERIAL
9 ft. ft. in.
Company Name ii ZL
��,y.y,,``-�,�.� 16.INNER CASING OR TUBING eothcrmal closed-loop)
llf*wa 2.Well Construction Permit#: an FROM TO DIAMETER THICKNESS 3ATERIAL
List all applicable well construction permits(i.e.UIC,County,0"qBzjrtq VrW ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIA,'*=ER SLOT SIZE THICKNESS bIATERLAL
❑Agricultural CJMunicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑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,soit/rock type,gmin size,etc
88 ft 108 ft Fine Sand,Course Sand&Limestone
4.Date Well(s)Completed: 1/25/2021 well ID# 42 108 ft- 118 ft- Clay,Sand,Limestone,Shell
5a.Well Location: 118 ft. 128 ft. Limestone/Clay/Pepper Sand
U.S. Navy 128 ft- 138 It- Limestone/Pepper Sand
Facility/Owner Name Facility ID#(ifapplicable) 138 ft- 158 ft Sand
158 ft- 178 ft- Limestone and Sand
Physical Address,City,and Zip 178 ft 188 ft- Limestone/Big Shell
Craven .21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one]at/long is sufficient) 22.C rtifieation:
433449.48 N 2636229.26 W
6.Is(are)the well(s): OPermanent or ❑Temporary nature of Cc
ifie ell Contractor Date
By signing this rm, hereby certify that the wens)was(were)consintcted in accordance wilb
7.Is this a repair to an existing well: ❑Yes or 11No 15A NCAC 02C. 00 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well constriction information and explain the native of the of this record has been provided to the well owner.
repair under 921 remarks section or on the back of 1his 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 construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 251 (ft) Submit this GW-1 within 30 days of well completion per the following:
For ntulliple ivells list all depths if different(example-3@200'and 2@100')
10.Static water level below top of casing: 28 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+^ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 29 (in,) 24b. For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rotary
24c.For Water Supp1Y and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm)
659 Method of test: 24hr. pumping Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 5 lbs.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018