GW1-2022-06988_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 15.OUTER CASING for multi-cased wells OR LINER if a licable
A.C. Schultes of Carolina, In FROM TO DIAMETER TIHCIM bATERIAL
2 ft. ft. in.
Company Name J� (� 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: JI` �ll�? FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i. . wle Variance,etc.) ft. ft. 1n.
3.Well Use(check well use): ev' R� �Ur( ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICXNESS MATERIAL
❑Agricultural OMunicipal/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)
FROM TO DESCRIPTION color,hardness,soil/mck e, min size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 80 ft. 90 ft- Sand/Shell/Limestone/Clay
4.Date Well(s)Completed: 11/1 7/2020 Well ID# 34 90 ft. 100 ft. Sand/Shell/Clay/Limestone
5a.Well Location: 100 ft' 120 ft- Fine Sand/Clay/Shell
U.S. Navy 120 ft- 190 ft. Sand/Traces of Limestone
Facility/Owner Name Facility ID#(ifapplicable) 190 ft. 269 ft. Limestone/Traces of Sand
ft. ft.
Physical Address,City,and Zip ft. ft.
Craven 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.C tification:
438289.41 N 2634620.29 W AA -71
-r as
6.Is(are)the well(s): [!]Permanent or ❑Temporary S' ature of CVifieN
Bysigningthisreby certify tl at dre well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or InNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200!Yell Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or an 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 construction info
construction,only 1 GW-I 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: 244 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdierent(exaunple-3@200'and 2@100')
24a. For All Wells: Original fonn to Division of Water Resources (DWR),
f Static water level below top of casing: 28 (fL) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If waterleve!is above casing,use"+"
11.Borehole diameter: 12 (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 Supply 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 produeing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm)
644 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