GW1-2022-09163_Well Construction - GW1_20220930

Or!rit Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Sean Cropsey 14.1VATER ZONES;- '
p
Well Contractor Name v 5�11 `t:-7-,! FROM TO DESCRIPTION�-',
82 f- 102 ft' Limestone,Sandy Limestone,Tan Limestone
2485-A ft. ft.
NC Well Contractor Certification Number S E P 2022 -- - I
5.,OUTER'CASINGI"Itiec�.iililK)*TO �MR ybl
ARM ljn� FROM To I DIAMETER'in. THICKNESS
MATERIAL
Company Name +1 f- 1 82 f- 1 4 8CH 401 PVC
413&JNNER1,GiVSINGT0R BING16ithernial'
2.Well Construction Permit#: EHWP-2022 -00034 FROM TO DIAMETER - I THICKNESS I MATERIAL
List a//applicable well construction permits(i.e.UIC,County.Slate,Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: W-nTAT"A1;1,D--1
7JFROM TO DIAMETER SLOTSIZE I THICKNESS I MATERIAL
Agricultural 13MunicipaVPublic
82 ft- 102 f- 4 in. 10 slot OCH 401 PVC
7IGeothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
3Industrial/Commercial [3Residential Water Supply(shared) jlSXGROUT &,,' 9 ��I f
71Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 20 "' Bentonite Chips Poured 14 baas
3Monitoring 13Recovery ft. ft.
Injection Well: ft. ft.
:)Aquifer Recharge 13Groundwater Remediation
219.4SANU/GRA�VEL4PXC,,K,(if.g-v—p livable)',
Aquifer Storage and Recovery [3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage 80 " 109 ft- #2 qravel poured 20 hRq-%
Experimental Technology [3Subsidence Control ft. ft.
Geothermal(Closed Loop) 13Tracer F002DRIEWING 11JOGIt—stiNclilad di d dirbi'she—etslifNeces—sa ;Z,amn
Geothermal(Heating/Cooling Return) [3Other(explain under 421 Remarks) FROM TO DESCRIPTION(color,hardness,saillrock type,grain sin,etc.)
0 1" 20 ft- Tan + Gray Clay
4.Date Well(s)Completed: 9/8/2022 Well ID# . 20 ft- 40 f- Wood- Gray Clay - Shells
5a.Well Location: 40 ft- 50 '1- Shells -gray silty sand
Chanda Cassidy 50 it. I rn 0 ft' Rnrk - Effinle Sand
Facility/Owner Name Facility ID9(if applicable) 60 ft. 70 ft' Umestone, Shells - Silty Clay
160 Graham Lane , Holly Ridge 28445 70 ft- 90 f` Gray Limestone, Sand Layers
Physical Address,City,and Zip
9 0 ft* 102 f* Tan Limestone . Silly, Tan Clay
Onslow 424800401577 n2REmARK
"I
Ixa� 7 I I .
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: r777-
(if well field,one lat/long is sufficient) 22.Certification:
34' 30'42" _N 770 31' 32" —W 52a,4t, 2,4�-e � 09/12/2022
6.ls(are)the well(s)opermancnt or [3Temporary Signature of Certified Well Con for Date
By signing this form,I hereby cerli;J,that t?,well(S)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or ONo with 15A MCAC 02C.0100 or 15A ArCAC 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 of this record has been provided to the well owner.
repair tinder Ul remarks section or on the hack qf1his.forin. 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 I GW-I 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: 102 ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list a//depths itdifferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 25 (ft.) Division of Water Resources;
Information Processing Unit,
/f 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) 259pm Method of test: Air Lift _ 24c. For Water Supply&In*ection 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: 1Lb 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