GW1-2022-07869_Well Construction - GW1_20220825

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1. Well Contractor Information:
Sean Cropsey 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2485 - A 73 ff 93 ft. Med and coarse sand
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
Applied Resource Management FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. I in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. UC,County,State, Variance,etc.) +1 ft. 73 ft. 4 in. Seh 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [:)Municipal/Public ft, ft in.
Geothermal(Heating/Cooling Supply) ®IResidential Water Supply(single) ft R• in.
�Industrial/Commercial [:]IResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 33 ft. Bentonite Poured 21 bags
Monitoring DRecovery
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
®IAquifer Storage and Recovery 01 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
rJAquifer Test [:]I Stormwater Drainage 70 ft 93 ft #2 Gravel Poured 20 bags
Experimental Technology [:]I Subsidence Control
rlGeothermal(Closed Loop) [:IITraeer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) IOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,wil/rock type,grain size,etc.
0 ft 20 ft. Gravel - Orange clay
4.Date Well(s)Completed: 8/1 6/2022 sell ID# 20 ff 30 ft Sticky grayclay
5a.Well Location: 30 ft. 40 ft. Med sand
John Boyette 40 ft 60 ft Fine, med, coarse gravel black woo )
Facility/Owner Name Facility ID#(ifapplicable) 60 ff 70 ff Hard gray clay
7308 Woodbridge Road Stanonburg, NC 27883 70 ft 90 ft Med, corse gravel with clay layers
Physical Address,City,and Zip ft. ft.
Wilson 3647-07-3893 2LREMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
35 36' 38" N 77 51' 27" w 8/16/2022
6.Is(are)the well(s):®IPermanent or E]ITemporary Signature of Certified Well onuact& Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [JIYes or ®No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature of the copy ofthis record has been provided to the well owner.
repair under 421 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 site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 93 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3CJ)200'and 2@100') construction to the following:
10.Static water level below top of casing: 33 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing use'—" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8 (in.) 24b. For Iniection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: Mud Rota rV
construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 30 Method oftest: Bucket 24c. For Water Supply& Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HtH Amount: 1 lb completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016