GW1-2021-07107_Well Construction - GW1_20211007

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Sean Cropsey q. 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2485-A Z02� 20ft. 38ft. rock
ry ft. ft.
NC Well Contractor Certification Number C :;�ECI�
15.OUTER CASING for mtilti-casedlwells OR LINER if a licable
Applied Resource Management. �I�0L10n FROM TO DIAMETER THICKNESS MATERIAL
r^ D�e}(3 a ft. ft. in.
Company Name
WC P-21-01143 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit 4: FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0 ft. 23 ft. 4 in. SCh 40 PVC
3.Well Use(check well use): ft. ft. in.
17.
Water Supply Well: FROM'SCREENTO DIAMETER SLOT SIZE THICKNESS MATERIAL
1 Agricultural OMunicipal/Public 23 ft- 38ft• 4 in- 10 slot SCh 40 PVC
❑Geothermal(Heating/Cooling Supply) E'Residential Water Supply(single) ft. ft. in.
,,)Industrial/Commercial [Residential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Oft• 20 ft. hole plug poured 11 bags
J Monitoring13-
Recovery ft. ft.
Injection Well: ft. ft.
DAquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
_I Aquifer Storage and Recovery OSalinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
J Aquifer Test n-lStormwater Drainage 20f° 38ft #2 Gravel Poured
Experimental Technology [3Subsidence Control ft. ft.
__I Geothermal(Closed Loop) n Tracer 20.DRILLING LOG attach additional sheets ifnecessa
FROM TO DESCRIPTION color,hardness,soil/rock e, rain size,etc.
J Geothermal(Heating/Cooling Return) _ Other(explain under#21 Remarks) 0 ft. 1 Oft- clay
4.Date Well(s)Completed: 09/10/2021 WeII ID# 10 ft. 20 ft. sand & shells
5a.Well Location: 20 ft- 35ft• rock
BecCa Ward 35 ft- 38 ft- fine sand to clay
Facility/Owner Name Facility ID#(if applicable) ft. ft.
27 Freeman Mckelvie Ln. Delco 28436 ft. ft.
Physical Address,City,and Zip ft. ft.
Columbus 2230.00-21-2390.000 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
34 18 2 N 78 13 51 W 09/27/2021
6.Is(are)the well(s)oPermanent or ©ITemporary Signature of Certified Well Conkfetor Date
_. 13v signing this form,I hereby certifv that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or ONo with 15A NCAAC 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 921 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: 38(ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths fdiffereni(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 13 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: $(in.) 24b. For Infection Wells: In addition to sending the form to the address in 24a
Mud Rotary 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) 10 Method of test: Pump 24c. For Water Supply& Iniecti n Wells: In addition to sending the form to
the address(es) above, also submitl one copy of this form within 30 days of
13b.Disinfection type: HtH Amount: 1 lb 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