GW1-2022-09979_Well Construction - GW1_20221104

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WELL CONSTRUCTION RECORD(GA-1) For Intemal Use Only,
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1.Well Contractor Information:
Rawlins Clarke IV 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
NCWC 4234-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING far malt[-cased webs OR LINER if applicable
Redox Tech FIIOnf TO DIAMETER! THICKNESS MATERTAL
ft. fL i 'in.
Company Name 16.INNER CASING OR TUBING eothermal closed lao
site of release FROM TO- DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft, ft. ;� �•
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)
ft. ft. �•
3.Well Use(check well use):
EN
Water Supply Well: 17.SCRE FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
[:]Agricultural ❑Municipal/Public 30 it. 25 ft in'
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft- 30 ft' la:
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METRO
❑IIIi ation D&AMOUNT
❑
Non-Water Supply Well: 22 ft. surface ft.
[!]Monitoring ❑Recovery
Injection Well:
uifer Recharge har a ❑Grotmdwater Remediation
Q g 19.SAND/GRAVEL PACK if a lkable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL
EMPLACEMENT METHOD
❑Stormwater Drainage 30 ft. 24 ft. sand poured
❑Aquifer Test '
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets
if necessary hardness soiVrock a size etc
FROM TO
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft•
10/14/2022 1 ft. ft.
Well ID#
4.Date Well(s)Completed:
5a.Well Location:
ft. it.
S&R Packageing &Crating
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
602 Sunnyvale Dr., Wilmington 28412 ft• ft.
ft. ft.
i 1n;Lr;ra;}zm Pr nit
Physical Address,City,and Zip D
21.REMARKS
New Hanover
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one lat/long is sufficient) 22. r (cation:
N W ib Z� 2A
XignaturcWAc-rtif�i�rdWcll Contractor Date
6.Is(are)the well(s): nPermanent or ❑Temporary
By signing this form,[hereby certify that the well(s)was(were)consirucied in accordance with
7.Is this a repair to an existing well ❑Yes or 19No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature ojthe
of this record has been provided to the well 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
(add'See Over'in Remarks Box).You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 30 (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� 1
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft') Information Processing Unit,161j7 MSC,Raleigh,NC 27699-1617
Ifwafer level is above casing,use
3.25 24b.For Iniection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in•) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Auger 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells produci a over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Ral6 igh,NC 27699-1611
13a.Yield(gpm) Method of test-
13b.Disinfection type: Amount:
Revised b-6-2018
n-s.e..,-„t�fRnvironmental Ouality-Division of Water Resources