GW1-2022-01641_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
0
Company Name .0 ft. 95 ft. 16 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.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public 0 ft. ft in.
Geothermal(Heating/Cooling Supply) [:)Residential Water Supply(single) 180 ft. tt in.
150 8 .030 Stainless
hidustrial/Commercial Residential Water Supply(shared) 18.GROUT
irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 145 ft- 135 ft- Bentonite Pour
Monitoring QRecovery 135 ft- 0.0 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 TestQlStormwaterDrainage 180 Ft. 145 ft #2 Sand Pour
Experimental Technology Subsidence Control
Geothermal(Closed Loop) QlTracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.)
NGeothermal(Heating/Cooling Return) M Other(explain under#21 Remarks) o ft. 15 ft. Med to dark brown fine sand
15 40 Mad gray silty clay
12/9/2021 12 40 ft. 50 ft. grayaiuymGay
4.Date Well(s)Completed: Well ID# 50 70 heusw ganyday
limestone71 85
5a.Well Location: ee t' 1117 t' light gray limestone
Aqua-Cape Water Resource 117 ft. 125 ft. gray limestone with shell and clay mixture
Facility/Owner Name Facility ID#(if applicable) 125 ft. 140 ft. gray soft sandstone with shell fragments
North of Jacob Mott Drive, Wilmington, NC 140 ft. 180 ft. gray sandstone with small shell fragment,some silt layers
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 7 49.225 N 77 54 2.539 w 12/9/2021
6.Is(are)the well(s)nlPermanent or 13Temporary Signature eCertified 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 Wo 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
1
9.Total well depth below land surface: 180 (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: 28r(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: 14.5 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: Mud Rotary 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) 70 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: HtH Amount: 1 1 b 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