GW1-2021-02467_Well Construction - GW1_20211015

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WELL CONSTRUCTION RECORD (GW-1 )
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Form GW-1 Well Construction Electronic Form
North Carolina Department of Environmental Quality
Division of Water Resources
April 1,2021
Submission ID#
GW 1-2021-02467
Are you submitting a printed form?* Yes
• No
CONTACT INFORMATION
.......................................................................................................................
Contact Name* Email Address*
Chris Schappell [e-mail]
Is this a revision to the form you have previously submitted?*
Yes No
WELL CONSTRUCTION INFORMATION
........ ......... ..... ......... ......... ......... ......... ..... .........
1.Who is installing these wells?*
Owner Well Contractor
1.Well Contractor Information:
Certiticate# Cert Level First Name Last Name Company Name
2332 A JOHN SCHAPPELL M&W Drilling LLC
2.Well Construction Permit#:
List all applicable well construction permits(i.e.Monitoring Wells,UIC,County,CCPCUA,etc.)
What type of well is this?* Injection Well Non-Water Supply Well
Water Supply Well(includes irrigation wells)
3.Non-Water Supply Well* Monitoring
Recovery
4.Date well was completed and ID#
Date Well Completed* Well ID# Well Yield
10/5/2021 IR82-MW112UCH (gallons per minute)'
5.Well Location
..................................................................................................................................................

Facility/Owner Name*
Camp Lejeune Facility ID#
(Required) (If applicable)
County*
Onslow
The selected county is within the Central Coastal Plain Capacity Use Area. Please reference your Capacity Use Water
Withdrawal Permit Number(CUxxxx)in Section 2.above.
Parcel Identification No.(PIN)
Physical Address* Street Address
Piney Green Road
Address Line 2
City State/Province/Region
Jacksonville INC
Postal/Zip Code Country
28547 USA
Latitude* 34.4134610000 Longitude*77.1934210000
Decimal degrees Decimal degrees
6.Is(are)the well(s):* Permanent Temporary
7.Is this a repair to an existing well:* Yes No
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this form.
For multiple Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction,only 1 GW-1 is needed.
8a.Indicate TOTAL NUMBER of wells drilled: 1
9.Total well depth below land surface: (ft.) 9a.What is the depth of the casing from ground
75 surface?
For multiple wells list all depths if different 65
(example-3@200'and 2@100') in feet
11.Borehole diameter:
10.Static water level below top of casing: (ft.) 6
If water level is above casing,use"+" in inches
12.Well construction method:
Auger Air Rotary Cable Tool
Direct Push Mud Rotary Rotosonic
Other
14.WATER BEARING/FRACTURE ZONES
From To Description
in feet in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)

From To Diameter Thickness Material
in feet in feet in inches
17.SCREEN
........................................................
From To Diameter Thickness Material
65.00 75.00 2.00 Sch 40 PVC
in feet in feet in inches
18.GROUT
From To Material Emplacment Method&Amount
0.00 58.00 Portland Cement/Bentonite Pumped via Tremie Pipe
in feet in feet Grout
19. SAND/GRAVEL PACK(if applicable)
From To Material Emplacment Method
63.00 75.00 #2 Medium Sand Pour
in feet in feet
20. DRILLING LOG
From To Description(color, hardness,soil/rock type,grain size,etc.)
in feet in feet
21. Remarks
5'bentonite seal between 58'and 63'
22.Site diagram or additional well details:
You may upload additional well construction information here.
pdf only
CERTIFICATION INFORMATION
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* By signing this form, I hereby certify that the well(s)was(were)constructed in accordance with 15A NCAC 02C.0100 or
15A NCAC 02C.0200 Well Construction Standards and that a copy of this record has been provided to the well owner.
23.Certification*
0;?;6v&4Sal�
Signature of Certified Well Contractor
Submittal Date 10/15/2021