GW1-2022-06990_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
4504-A 199 ft. 239 ft. Limestone
r ft. ft.
v
NC Well Contractor Certification Number l 15.OUTER CASING for mulfi-cased wells Pill,INER if a licable
A.C. Schultes of Carolina, Inc. JUL FROM TO DIAMETER THICKNESS MATERIAL
2 t��AoZt 0 ft. 49 ft. 24 in.
Company Name �as
16.INNER CASING OR TUBL'VG(geothermal closed-loop)
2.Well Construction Permit#: B; _ FROM I TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC County,Stare,Tolmce,etc) 0 ft. 199 ft. 12 "' .75" PVC SDR17
3.Well Use(check well use): 239 ft- 244 ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural nMunicipal/Public 199 ft. 239 ft. 12 in. 0.050 304 SS
❑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 DL1TEREAL EMPLACEMENT DIETHOD&AMOUNT
Non-Water Supply Well: 0 ft. 186 ft. Slurry Tremmie
[]Monitoring ❑Recovery 186 ft- 189 ft- Bentonite Tremmie
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 ❑StonnwaterDrainage 189 ft. 244 ft. Southern#3 Tremmie
❑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 421 Remarks) FROM TO DESCRIPTION color,hardness,soilfrock type nin size,eta
0 ft• 10 ft• Fine Sand/Red Clay
4.Date Well(s)Completed: 11/17/2020 well ID# 34 10 ft• 30 ft Soft Clay/Some Shell
5a.Well Location: 30 ft. 40 fc Clay/Coarse Sand/Trace of Limestone
U.S. Navy 40 ft. 50 ft. Clay/Coarse Sand/Trace of Limestone
Facility/Owner Name Facility ID#(ifapplicable) 50 ft. 60 ft Clay/Shells
60 ft. 70 ft. Sandy/Clay
Physical Address,City,and Zip 70 ft• 80 ft. Fine 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 latAong is sufficient) 22.C tification:
438289.41 N 2634620.29 W
6.Is(are)the well(s): CJPermanent or ❑Temporary S' azure of erti R d 1 Contractor Date
By signing this fora I ereby certfy th lithe ivell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ilNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
!f this 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 on 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-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: 244 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3@200'and 2@100')
28 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lfwater level is above casing,use
11.Borehole diameter: 12 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 Ibs
I
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018