GW1-2022-08348_Well Construction - GW1_20220829

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor information:
Brian James Bellis 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
NCWC 3510-A 1.92 ft. >10 ft- Water table
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased'wells)OR LINER(ifap livable)
WithersRavenel, Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 1.14 ft• 2:0 in. I Sch. 40 PVC
Company Name
N"/� 16.1NNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: ' " FROM TO DIAMETER THICKNESS MATERIAL
Lisl all applicable well cons7ruction permits(i.e.U1C,Connly Stale,Variance,elc•.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Su 1 Well: 17.SCREEN
pp y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
0Agricultural Municipal/Public 1.14 ft. 6.14 ft. 2.0 in. 10 Sch.40 PVC
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft in.
Industrial/Commercial ®I Residential Water Supply(shared) I&GROUT
1trigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ff• 1.5 ff• Concrete Pour
X Monitoring 13 Recovery ft. ft.
injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable
Aquifer Storage and Recovery Salinity Barrier FROM TO I MATERIAL EMPLACEM ENT METHOD
Aquifer Test [)Stormwater Drainage 1.5 fit- 6.14 ft- Sand UST excavation backfill
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) E3Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) MOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soillmck type,V"n size,etc.
0 ft- 6.14 ft, Clean sand backfill
4.Date Well(s)Completed:8/22/2022 Well ID#MW-1 ft. ft.
5a.Well Location: ft. ft.
Wagon Wheel Facility 0-0-3297 ft. ft. F-Z'., y ;� s•�•*�t
Facility/Owner Name Facility ID#(if applicable) ft. ft.
114 Wagon Wheel Lane, Rose Hill ft. ft. AUG.
Physical Address,City,and Zip ft. ft.
Duplin 248000945877 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certification:
34.858460 N -78.034459 W �e-�-�-8/23/2022�
6.Is(are)the well(s)oX Permanent or Temporary Signature ofCertifi Well ontractor Date
By.signing this form,1 hereby certify that the we//(s)was(here)constnrcled in accordance
7.Is this a repair to an existing well: [DYes or )No with 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
Ifthis is a repair,Jill out known well construction information and explain the nature of the copy of this record has been provided to file well owner.
repair under 1�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 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: 6.14 -(ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For nudliple wells list all depths ifdii ferent(example-30100'and 2@100') Construction to the following:
10.Static water level below to of casing: 1.92 ft.
p I;� ( ) 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:3.0 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Installed in UST Excavation while backfilling above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 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) NA Method of test: NA 24c. For Water Supply&Infection 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. NA Amount: NA completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016