GW1-2021-02260_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 5.7 rt. >g Waterta�bie
fr. ft. i
NC Weil Contractor Certification Number 15.OUTER CASING for mulfi-cased wells)OR LINER if a licable
WithersRavenel, Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 3 e. 1 2.0 , in. Sch. 40 PVC
Company Name
N A 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#•" "" FROM TO DIAMETER THICKNESS MATERIAL
list cell applicable well construction pernrlts(i.e. (JIC,C'ouniV,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): R. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public 3 ft- $0 It. 2.0 in. 10 Sch. 40 PVC
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in;
Industrial/Commercial Residential Water Supply(shared) I&GROUT
-Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 1.5 ft- Concrete Pour
x Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge QGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stonnwater Drainage 2.0 ft 10.0 ft, Sand UST excavation backfill
_Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soilimck rain size,etc.
)0 ft. 1.0 ft- Topsoil backfill
4.Date Well(s)Completed:6/29/2 1 Well ID#MW-2 1.0 ft 8.0 rt• Clean sand backfill
5a.Well Location: ft. ft. to
Castle Street Property 0-0-44628
Facility/Owner Name Facility ID#(if applicable) ft. ft. 21
1220 Castle Street, Wilmington 28401 ft. ft.
Physical Address,City,and Zip ft. ft. rJrpOP, S1ng Un
New Hanover R05410-008-025-000 21.REMARKS
J
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-
34.228820 N -77.932159 W
7-14-21
6.Is(are)the well(s)oPermanent or 13Temporary Signature ofCertified well -tractor Date
r
4v signing this Jorm,1 hereby cert�that the wells)was(mere)constructed in accordance
7.Is this a repair to an existing well: QYes or x)No with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
lJ'this is a repair,fill out known well construction information and explain the nature ofthe copy ofthis record has been provided to the well owner.
repair under s21 remarks section or on the back oJ'this Jorm.
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 ofwells construction details. You may also;attach additional pages ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 8'07 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@l00') construction to the following:
10.Static water level below top of casing:5.77 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
k
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.) f
i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) NA Method of test: NA 24c. For Water Supply& Infection Wells1: 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 Deparnnent of Environmental Quality-Division of Water Resources Revised 2-22-2016