GW1-2021-07417_Well Construction - GW1_20210921

t.LL CONSTRUCTION RECORD(GW-1) For internal Use only:
5 1.Well Contractor information: ��
George briagei ✓` gC WATER ZONES
:Well Contractor Name TV1.
�9` Off ft' 3TO R' DESCRIPTION
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2393Ao�
NC Wcll Contractor Certification Number �� �gG� `1SrOlJlER'CASTNG for mWd i+db OR L'WER" i (able �'
Carolina Drilling . �a��`30`�� moll To fL
n DUMETER i^ THICKNESS nATERIAL
Company Name � / Q ,
U I C#Y Y l 0 V 00�28 16. -CASING OR:TUB
2.Well Construction Permit k FROM TO DIAMETER I THICKNESS MATERIAL
list all applicable will comsYrvcunn permits(t,e.111C.Cntwrp,More.I oriance,e1c.) 0• ft. In.
3.Well Use(check well use): ft R to
17:SCREEN.'. �'�-.��� ':,r'�.-,���✓ yr,`:.-�.�c"-.����s rrr•
Water Supply Well: FROM TO I DIAMETER I SLAT SIZE I THICKNESS nuTERiAL
OAgricultural OMunicipal/Public R ft. In
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) R• n• in
❑Industrial/Commercial OResidential Water Supply(shared)
Olrri ation OWells>100.000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Wa ter Supply Well: n' ft.
OMonitoring ORecovery n. A.
Injection Well: ft ft.
OAquifer Recharge MGroundwater Remediation _ -
i'19FSAND/GRAVEIAPAG'K
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL i:l11PLACEMUMMErHOD
OAquiferTest OStorinwater Drainage ft. ft.
OExperimental Technology dSubsidence Control n• n•
OGcotherrnal(Closed Loop) OTracer e2WDRILMING tAG fttiebiddltlo`nwlytteNa if.6toenii" = ,-,.. •
FROM TO DESCRIPTION eoton hardness.salt/rock lee in size.etc.
OGeothermai(HeatinglCooling Return) OOther(explain under i121 Remarks) ft. n
4.Date Well(s)Completed: August 25.31,2021 Well IDfI N/A n, fL
n. ft.
5a.Well Location:
Pm�erYOMn,tlrye ..rrl tawbrro� l�0en.. DSCA ID#65-0001
Facility/Owner Name Facility IDN(ifopplicable) fL ft.
3750 Oleander Drive, Wilmington, NC 28403 ft. ft.
Physical Address,City.and Zip ft. n,
New Hanover '21.-REMARKs�:-
County Parcel Identification No.(PIN) 19 geoprobe borings were drilled to a depth of 30 feet.
5b.Latitude and longitude In degrees/mloutes(seconds or decimal degrees:
(if well field,one IaVlong is sufficient) 22.
n:Certificatio
171013.833 N 2331802.645 �,, r /� l3 uZ i
6.Is(are)the well(s): ❑Permanent or 19Temporary ofCerti i Well or Date
i
signing this form,l hereMy certify that the well(s)tray(were)cmrviructed hr acron/aice with
7.Is this a repair to an existing well: ❑Yes or ItNo MA NCAC 02C.0100 or 1 SA Ak:A('02('.0200 tYell C'onsiniciiat Siatdanlr and tlmi a copJy
If this is a repair,fill aid!clown hry cwLvrmcimu information acid esplani the naltire of the of this record hav been pr ar ded to the aril owner.
repair muter 41 remarks secrion or ai 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 construction info
construction,only I GW-i is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:to 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 19@30' (ft.)
For multiple trills ha all depilts rfd perrw(example-3 a2011'and 2(n100') Submit this GV('-)within 30 days of well completion per the following:
' 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 6 (ft.) information Processing Unit,1617MSC.Raleigh,NC 27699-1617
If hater lerW is above casing,use"
11.Borehole diameter. 2 (in.) 24b.For Injection\Yells:Copy to DWR,Underground Injection Control (JUC)
Program. 1636 MSC,Raleigh,NC 27699-1636
12.Well rnpstrvction method: directush !24c.For Water Supply and Otich-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health depat uttent of the county where installed
FOR RATER SUPPLY WELLS ONLY: 24d.For Water\yells roducin i over 100.000 GPD:Copy to DWR,CCPCUA
Permit rogram,1611 MS ,R et C 27699- 611
13a.Yield(gpm) N/A Method of tcst. Nl �A i
13b,Disiarection type:N/A Amount:NIA
Form GW-I North Carolina Department of Environmental Quality-Division of Warer Rescurccv Revised 6.6.2018
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