GW1-2022-01635_Well Construction - GW1_20220202

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Sanford Sweeting 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
2082-A ft ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
Applied Resource Management FROM TO DIAMETER THICKNESS MATERIAL
Company Name Oft. 1 80 ft. 1 18 in. Sch 40 PVC
16.INNER CASING OR TUBING eother al closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) [:)Residential Water Supply(single) ft. tt in.
129 gg 10 .030 Sch 40 Stainless
lndustrial/Commercial Residential Water Supply(shared) 18.GROUT
atlOri FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
�Irn
on-Water Supply Well: 94 ft. 84 ft. Bentonite Pour
Monitoring ORecovery 84 ft. 0 ft. Neat Cement
Tremmie
Injection Well: ft. ft.
PAquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
DAquifer Storage and Recovery [:)Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
QAquifer TestE3 Stormwater Drainage 129 ft- 94 It- #2 Pour
Experimental Technology [3 Subsidence Control ft. ft.
Geothermal(Closed Loop) QlTracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock e, rain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
0 ft. 20 ft- Dark brown fine sand
4.Date Well(s)Completed: 12/17/2021 Well ID# 1 O-B 20 ft' 40 ft- Gray med to coarse sand
5a.Well Location: 40 ft' 60 ft. Gray clay with fine sand layers
Aqua-Cape Water Resource 60ft. 92 It- gray silty clay
Facility/Owner Name Facility ID#(if applicable) 92ft. 96 ft. Shell hash with limestone fragments
7334 Carolina Beach Road, Wilmington, NC 96 ft. 129 ft. Limestone and sandstone mix
Physical Address,City,and Zip ft. ft.
New Hanover 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
34 04 36.88 N 77 54 25.80 w � �'
� 12/17/2021
6.Is(are)the well(s)El Permanent or [3Temporary Signature of t1itified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or ®No with 15A NCAC 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#21 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: 129 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 20 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 17 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: Mud Rotary above, also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 250 Method of test: Air Lift 24c.For Water Supply&Iniection 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