GW1-2021-07653_Well Construction - GW1_20211214

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Austin Fowler It WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
4366-A
ft. ft.
NC Well Contractor Certification Number I&OUTER CASING far add-CNW WVW OR LINER ifs "ble
CATLIN Engineers and Scientists FROMtTO DIAMETER THICKNESS MATERIAL
0.0 .5 ft- 2 i" SCh. 40 PVC
Company Name
16.INNER CASING OR TUBING tlteraul dasaa-too
2.Well Construction Permit#: N/A FROM TO DIAMETER THICKNESS NI ITFR1,11
List all applicable well construction pernnte(i a I11 .('outO,State. I aruance,etc) ft. ft. in
3.Well Use(check well use): ft. R. in.
Water Supply Well: FROM TO DIAMETER SLOT SIZE I THICKNESS I MATERIAL
Agricultural [Municipal/Public 6.5 ft• 16.5 ft- 2 t"- Slot.010 I Sch. 40 JPVC
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. i"•
Industrial/Commercial Residential Water Supply(shared) I&GROUT
Irri atlon FROM TO MATERIAL EMPLACEMENI METHOD&AMOt "r
Non-Water Supply Well: 1.0 ft- 4.0 ft• Bentonite Pellets Surface Pour, 891b
x Monitoring [Recovery 0.0 ft- 1.0 It, Concrete Surface Pour, 801b
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK [ bk
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [Stormwater Drainage 4.0 ft. 16.5 ft- #2 Medium Sand Surface Pour
Experimental Technology Subsidence Control ft.
Geothermal(Closed Loop) [Tracer 20.DRILLING LOG at4ch additional sheets if necessa
FROM TO DESCRIPTION(rotor,hardness,soil/rock type. 14in size.etc.
Geothermal(Heating/Cooling Return) Other(explain under M21 Remarks) ft. ft.4.Date Well(s)Completed:11/16/2021 Well ID#11 8GW08R ft. ft. OEC 1 4 2021
ft. ft.
5a.Well Location:
MCAS Cherry Point N/A ft. ft.
� IN,
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Bldg. 133 Harrison St., Cherry Point, NC 28532 ft. ft.
Physical Address,City.and Zip ft. ft.
Craven County N/A 21.REMARKS
County Parcel Identification No (PIN) REPLACEMENT WELL-
SEE ORIGINAL DRILLING LOG
lib.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certification:
34.89248210 N -076.89967770 w 11/24/2021
6.Is(are)the well(s) x Permanent or [Temporary Signature of CertifiedWell Contractor Date
By signing this/firm,I herehv centJy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [Yes or X[No with I5A NCAC 02C.0100 or 15A NCAC 02C.01(N)Well Construction Standards and that a
Iflhis 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=21 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: 16.5 (ft.)
P 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if d(J)erenr(example-3 a200'and 1a/00') construction to the following:
10.Static water level below top of casing:7.0 (ft.) Division of Water Resources,Information Processing Unit,
If warer 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.field(gpm) Method of test: 24c. For Water Suanly & 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-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016