GW1-2022-06989_Well Construction - GW1_20220725

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Irvinn Bautista 14.WATERZONES
Well Contractor Name FROM TO I DESCRIPTION
206 ft- 246 ft• Linestone
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, Inc. 7 FROM To DIAMETER TIIIc1QVEss MATERIAL
Company Name
�� 0 ft- 60 ft- 24 in Steel Pipe
b
16:INNER CASING OR TUBING eothermal'closed-loo
2.Well Construction Permit M P FROM TO DIAMETER THICKNESS MATERIAL
List all applicable tireh'construction permits(i.e.UIC,Cozmty St Up4 0 ft- 206 ft- 12 'n' .75" 1 PVC SDR-17
3.Well Use(check well use): 246 ft. 251 ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
❑Agricultural [IMunicipal/Public 206 ft• 246 ft- 12 in. 0.050 304 SS
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) is.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 188 ft, Slurry Tremmie
❑Monitoring ❑Recovery 188 ft- 191 ft- Slurry Tremmie
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Retnediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAI. EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 191 ft• 251 ft- Southern#3 Tremmie
❑Experimental Technology El Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) FROM TO DESCRIPTION color,hardness,soillrock type.grain size,etc.
0 ft• 10 ft- Red Clay
4.Date Well(s)Completed: 10/22/2020 Well ID# 35 10 ft- 20 ft- Grey Clay/Shell Trace
5a.Well Location: 20 ft 40 ft- Clay,Shell, Fine Sand
U.S. Navy 40 ft- 50 ft- Fine Sand/Clay
Facility/Owner Name Facility ID#(ifapplicable) 50 ft• 60 ft- Clay/Traces of Shells
60 fr. 70 ft- Sandy Clay
Physical Address,City,and Zip 70 ft. 100 ft- Course Sand/Shell/Clay
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) P
Cc
436470.16 N 2635337.76 W6.Is(are)the well(s): InPermanent or ❑Temporary We l Con1?4CO2C
Date
, hereby ce the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or PJNo 15A NCAC 0 C 100 or 15A N .0200 Well Construction Standards and that a copy
fills is a repair,fill out known well construction it formation and explain the nature of the of this recor s been provided to the well ovmer.
repair under#21 remarks section or on the hack 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-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 multiple ivells list all depths li dierent(example-3@200'and 2@100')
28 24a. For All Wells: Original form to Division of Water Resources (DWR),
f Static water level below top of casing: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use"+"
II.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 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 producing 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