WQ0023693_GW-1_20191218

WELL CONSTRUCTION RECORD (GW-1)
Print Form
For Internal Use Only:
1. Well Contractor Information:
Douglas Hewett, II
Well Contractor Name
4392-A
NC Well Contractor Certification Number
Hewett's Well Drilling & Pump Service, Inc.
Company Name
2. Well Construction Permit #:
ldsi all applicable tvell construction permits (i.e. UIC, County, State, Variance, etc)
3. Well Use (check well use):
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
Non -Water Supply
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling
4. Date Well(s) Completed: 12-8-1 9
[]Municipal/Public
Residential Water Supply (single)
Residential Water Supply (shared)
[]Groundwater Remediation
[]Salinity Barrier
[]Stormwater Drainage
[]Subsidence Control
Tracer
under #21
WellID# MW # 7
Sa. Well Location:
Brunswick County PPI 007
Facility/Owner Name Facility IDit (if applicable)
560 Bypass Way Ne Bolivia
Physical Address, City, and Zip
Brunswick
County
Parcel Identification No. (PIN)
Sb. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field, one lat/long is sufficient)
N
6. Is(are) the well(s)#Permanent or []Temporary
14. WATER ZONES
FROM
TO
DESCRIPTION
27 ft'
17 ft-
15. OUTER CASING or multi -cased wells OR LINER ifa licable
FROM
TO
DIAMETER
THICIQVFSS
MATERIAL
17 ft•
I top ft.
2 In. I
sch 40
Dvc
16. INNER
CASING OR
TUBING eothermal
closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
fL
In.
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOTSIZE
THICKNESS
MATERIAL
0 ft.
ft.
In.
27 1-
17 1-
2 In
.010
sch 40
Dvc
18. GROUT
FROM
I TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
15 ft.
top ft•
bentonitE
chiDs Dour
tt.
fr.
ft.
ft.
19. SAND/GRAVEL PACK if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
27 ft.
15 ft.
sand #2
ft.
ft.
20. DRILLING
LOG attach additional sheets ifnecessary)
FROM
TO
DESCRIPTION color, hardness, sailfrock type, Itrain sim etc.
0 ft•
10 ft•
clay
10 ft•
15 ft•
sand
15 ft.
20 It-
fine sand
20 ft•
27 ft
sand
27 ft.
ft.
clav
ft.
ft.
ft.
ft.
21. REMARKS
22. Certification:
W
1 11 44— fi�
ure o ified Well Contractor Date
7. Is this a repair to an existing well: []Yes or nNo
If this is a repair, fell out known well construction information and explain the nature of the
repair under 421 remarks section or on the back ofthis form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only l GW-I is needed. Indicate TOTAL NUMBER of wells
drilled: 1
9. Total well depth below land surface: 27 (ft.)
For multiple wells list all depths ifdii ferew (example- 3@200' and 2©100')
10. Static water level below top of casing: 6 (ft.)
If water level is above casing, use "+
11. Borehole diameter: 6 (in.)
12. Well construction method: rotary
(i.e. auger, rotary, cable, direct push, etc.)
By signing this form, I hereby certify that the well(s) was (were) constructed in accordance
with 1 SA NCAC 02C .0100 or 1 SA NCAC 02C . 0200 Well Construction Standards and that a
copy of this record has been provided to the wet! owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
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
construction to the following:
Division of Water Resources, Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center, Raleigh, NC 27699-1636
13s. Yield (gpm) Method of test: 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: sterllne Amount: completion of well construction to the county health department of the county
where constructed.
Forth GW-1 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016