GW1-2021-07650_Well Construction - GW1_20211214

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Austin Fowler 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
4 ft, ft.
366-A
ft. ft.
NC Well Contractor Certification Number 15.pUTERCASING fart#u1ti ea.Stdwtlle (}RLINER tta bit
CATLIN Engineers and Scientists FROM I TO DIAMETER THICKNESS MATERI L
0.0 ft. 20.5 rt• 2 i SCh. 40 PVC
Company Name
16.INNER CASING t71t TUl31NG ma!closed-too
2.Well Construction Permit#: N/A FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pernut.s(t.e U/C',C'ounil'.State, Torrance.etc) in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [)Municipal/Public 20.5 ft, 30.5 It- 2 r"' I Slot.010 SCh. 40 PVC
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) h. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18 GROU1
Irri atlon FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 1.1 It- 10.0 ft- Bentonite Pellets Surface Pour, 2661b
x Monitoring Recovery 0.0 It- 1.0 ft- Concrete Surface Pour, 801b
Injection Well: ft. R.
Aquifer Recharge ®Groundwater Remediation
19.SAND/GRAVEL PACK if icxble
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [)Stormwater Drainage 10.0 ft. 30.5 ft- #2 Medium Sand Surface Pour
Experimental Technology 13Subsidence Control ft. ft.
Geothermal(Closed Loop) QTracer 20.DRILLING LOG attacL additional sheets if neeeasa
FROM TO DESCRIPTION color,hardness,soil/rock e, rain sae,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
4.Date Wells)Completed:11/16/2021 Well ID#52GW76R
5a.Well Location: ft. H.
MCAS Cherry Point N/A ft. ft. h'�°'•r o
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Bldg. 133 Harrison St., Cherry Point, NC 28532 ft. ft. DEC t 4 ?Q?,)
Physical Address,City.and Zip
Craven County N/A 21.REMARKS
County Parcel Identification No (PIN) REPLACEMENT WELL-_
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: SEE ORIGINAL DRILLING LOG
(if well field,one lat/long is sufficient) 22.Certification:
34.89233790 N -076.8995241° N, 11/24/2021
6.Is(are)the well(s)o% Permanent or Temporary Signature of Certified Well Contractor Date
By signing this form,l hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [)Yes or x[)No with 15A NCAC 02C.0100 or 15A NC'AC 02C.0100 Well Construction Standards and that a
//this is a repair,Jill out known well construction information and explain the nature of the copy 4/this record has been provided to the well owner.
repair under=11 remarks section or on the hack 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 I GW-I 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: 30.5 Oil-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells Its/all depths tf different(example-3 a 100'and 1 r_t 100') construction to the following:
10.Static water level below top of casing: 10.5 (ft.) Division of Water Resources,Information Processing Unit,
//water level is above casing,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8•25 (in.) 24b. For Infection Wells: In addition to sending the form to the address in 24a
H.S. Auger 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) Method of test: 24c. For Water Supply & Infection 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: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016