GW1-2021-03352_Well Construction - GW1_20210603

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Sean Cropsey 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2845-A 165 ft- 190ft• Sandstone
ft. ft. j
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable
Applied Resource Management FROM TO DIAMETER THICKNESS MATERIAL
Oft• 168 ft- 4in• $Ch 40 PVC
Company Name 16.INNER CASING OR TUBING eotbermal closed-loop)
2.Well Construction Permit#: FROM I To I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft ft in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
J Agricultural [3Municipal/Public 170ft 190ft 2 in. 10 SCh 40 PVC
Geothermal(Heating/Cooling Supply) (_;Residential Water Supply(single) ft• ft in.
J Industrial/Commercial OJ Residential Water Supply(shared) 18.GROUT
vol-lIrrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: oft. 20 ft. Chips Poured 8 bags
_,;Monitoring - EIRecovery - ft.- ft.
Injection Well: ft. ft.
_ Aquifer Recharge ®Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
— Aquifer Test OStormwater Drainage ft. ft.
1
Experimental Technology []Subsidence Control ft. ft
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessa
_)Geothermal(Heating/Cooling Return) J Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness soil/rock type,grain size etc.
0 ft. 20ft• Clay&sand layers
4.Date Well(s)Completed: 05/03/2021 Well ID# loft• 40ft• clay to shells
5a.Well Location: 40 ft. 45 ft. coquina
Tim Brock 45ft• 150ft• Limestone
Facility/Owner Name Facility ID#(if applicable) 150 ft 165 ft. dark mu
33 Long Point Estates Hampstead, NC 28443 165 ft. 190ft• Sandstone
Physical Address,City,and Zip ft. ft. JU e7
Pender 3291-06-2197-0000 21•REMARKs 1
County Parcel Identification No.(PIN) lilt arrl;a
v
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one tat/long is sufficient) 22.Certification:
34 20 14 N 77 42 27 w 05/04/2021
6.Is(are)the well(s):0Permanent or EITemporary Signature of Certified WA Contr or Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DJ Yes or Ej 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 k21 remarks section or on the hack 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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 190(ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferew(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 15 (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above caring,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8 (in.) 24b. For Infection Wells: In addition to sending the form to the address in 24a
Mud Rota above, also submit one copy of this'forn within 30 days of completion of well
12.Well construction method: 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 Cet'ter,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test. 24c. For Water Sunoly& Iniectiori Wells: In addition to sending the form to
the address(es) above, also submit lone copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016