GW1-2022-06991_Well Construction - GW1_20220725

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Irvinn Bautista 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4504-A ft. ft.
NC Well Contractor Certification Number 15:OUTER CASING for multi-cased wells OR LINER if a &cable
A.C. Schultes of Carolina, Inc. FROM TO DIAMETER THICKNESS bfATERLIL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,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 [nMunicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑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 Retnediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO ilIATERIAL EMPLACEME IET OD
❑Aquifer Test ❑Stormwater Drainage ft. ft. ��'
❑Experimental Technology ❑Subsidence Control ft. ft. P
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROIII TO DESCRIPTION color,hardness,soillrock e,ggma tc.
100 ft. 110 ft- Fine Sand
4.Date Well(s)Completed: 10/22/2020 Well ID# 35 110 ft- 120 ft- Sand,Traces of Clay&Limestone
5a.Well Location: 120 ft' 140 ft- Fine Sand
U.S. Navy 140 ft- 150 ft- Sand/Some Shell
Facility/Owner Name Facility ID#(ifapplicable) 150 ft. 270 ft- Limestone,3'Clay 194'-197'
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]at/long is sufficient) 22.Cc ification:
436470.16 N 2635337.76 W I ,
"d 7 �gaa-
6.Is(are)the well(s): CJPermanent or ❑Temporary mature of Cert ed ell Contractol-71, Date
By signing lhisf nh, hereby certt that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo ISA NCAC 02C. 00 or l iA N C 02C.0200 Well Construction Standards and that a copy
If This is a repair,fill out known ivell construction information and explain the nature of the of this record has been provided to the hell 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: 251 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(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
Ifwaier level is above casing,use"+"
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 Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct posit,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 27699-1 6 1 1
13b.Disinfection type: HTH Amount: 5 lbs.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018