GW1-2022-08319_Well Construction - GW1_20220516

Prnt�Form -x
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: 7
Sean Cropsey 14.WATER ZONES
Well Contractor Name FROM TO I DESCRIPTION
2485-A 155 ft 180 ft
ft ft
N.0 Well Contractor Certification Number 15.OUTER CASING;for multi cased`,'wells OR LINER'if,a 'livable
Applied Resource Management, PC FROM TO DIAMETER THICKNESS MATERIAL
Company Name
0 ft r5 ft 8 I i" SCH40 PVC
16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: OSWPWP-22-0031 FROM TO DIAMETER THICKNESS MATERIALW
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) +1 ft 160 ft 4 1°' SCH 40 PVC
3.Well Use(check well use): ft ft in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public 0 160ft 180 ft 4 tn. 10 Slot SCH 40 PVC
Geothermal(Heating/Cooling Supply) gResidential Water Supply(single) ft ft in.
Industrial/Commercial Residential Water Supply(shared) IS.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 55 ft Bentonite Poured 23 Bags
Monitoring DRecovery ft ft
Injection Well:
ft ft
Aquifer Recharge E3Groundwater Remediation
19.SAND/GRAVEL=PACK"ifa -licatile _
Aquifer Storage and Recovery [Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E)Stormwater Drainage ft fL
Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach sidditionsl.sheets ifnecess
Geothermal(Heating/Cooling Return) 00ther(explain under 421 Remarks) FROM I TO DESCRIPTION color,hardness,soil/rock type,grain size etc.
0 ft 15 ft Clay D
4.Date Well(s)Completed: 3/23/22 Well ID# 15 ft 30 ft Sand Shells
5a.Well Location: 30 ft 55 ft Shells'mud MAY ] G 202
Cameron Edwards 55 f` 140 f` Limestone PFG-6401A)UM
Facility/Owner Name Facility ID#(ifapplicable) 140 f` 160 ft Sandy mud rock (X-VQ/8Od
174 Soundview Drive Wilmington, NC 28409 160 f` 180 f` Sandstone
Physical Address,City,and Zip It. ft
New Hanover R00213-007-001-000 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.Certification:
340 09 12.61 N 077' 57 36.73 W -!�aa4f, � 3/29/22
6.Is(are)the well(s)JRPermanent or [`Temporary Signature of Certified ell C66ractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: JnYes or D&No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this farm.
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: t SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 180 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 20 (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 Rotary 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) 50 Method of test: Airlifted 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: 110 completion of well construction to the county health department of the county
where constructed.
i
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016