GW1-2021-02259_Well Construction - GW1_20210722

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Brian James Bellis 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
NCWC 3510-A 5•9 ft. >10 ft. Water table
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for mulfi-cased wells OR LINER if a licable
WithersRavenel, Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 5 ft- 2 0 Sch. 40 PVC
Company Name
N"/� 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: ' " FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well con.struc•0nn permits(i.e. (/IC,Ccnonv,State, I�ariance.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 5 ft- 10 ft' 2.0 'n' 10 Sch.40 PVC
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) R. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ff• 1.5 fr• Concrete Pour
x Monitoring QRecovery
Injection Well:
ft. ft.
Aquifer Recharge GroundwaterRemediation 19 SAND/GRAVEL PACK ifa licable
_i Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E)Stormwater Drainage 2.0 ft- 10.0 ft. Sand UST excavation backfill
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets ifnecessa "
Geothermal(Heating/Cooling Return) r3Other(explain under#21 Remarks) FROM I TO DESCRIPTION color,hardness,soillrock type,gnin size,etc.
0 ft- 1.0 ft- Crushed stone backfill
4.Date Well(s)Completed:6/28/21 Well ID#MW-1 1.0 R• 10.0 ft• Clean sand backfill
5a.Well Location:
Castle Street Property 0-0-44628 ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. y��
1220 Castle Street, Wilmington 28401 ft. ft. f, Zp
Physical Address,City,and Zip ft. ft.
New Hanover R05410-008-025-000 21.REMARKS ,, -ro U
�ri�Jlti• `• pI r �g�t.
County Parcel Identification No.(PIN) �y t
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certification:
34.228820 N -77.932159 W
_ 7-14-21
6.Is(are)the well(s)o Permanent or 12Temporary Signa a of Certified tll Co ctor Date r
/3v signing this form,1 hereby certify that the u•e/M)was(were)constructed in accordance
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7.Is this a repair to an existing well: []Yes or E)No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards an¢that a
/fthis•is a repair,Jill our known well construction information and explain the nature oJ'[he copy of dtis record has been provided m ahe well owner.
repair under`2/remarks section or on the back o/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-I is needed. Indicate TOTAL NUMBER ofwells construction details. You may also';attach additional pages ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: 10. (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For nm/tip/e wells list a//depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below to of casing:5'98 ft.
P g� ( ) Division of Water Resources,Information Processing Unit,
/f uvaier level is above casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:3.0 (in.) 24b. For Infection Wells: In addition to sending the form to the address in 24a
Installed in UST Excavation while backfilling 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
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13a.Yield(gpm) NA Method of test: NA 24c. For Water SuoDly& 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: NA Amount: NA 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
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