GW1-2022-05761_Well Construction - GW1_20220615

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WELL CONSTRUCTION RECRARLVOW-1) For Internal Use Only:
1.Well Contractor Information:
Sean Cropsey ltli�i 13 2�22 14.WATER ZONES
Well Contactor Name FROM TO DESCRIPTION
2485 -A NC 175 f` 204 f` Limestone
Central Office ft. I ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR LINER if a licable)
ARM FROM TO DIAMETER THICKNESS MATERIAL
0 f`• 184 f`• 4 SCH 40 PVC
Company Name 16.INNER CASING OR TUBING eo'thermal closed-loop)
2.Well Construction Permit#: 265523-2 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well consiniction permits(i.e.UIC,Couniv.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
PAgricultural Municipal/Public 184 ft. 204 ft. in. 10 SCH 40 PVC
NGeothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q It. 20 ft. Benton ite•Chips Poured 29 Bags
Monitoring DRecovery ft. ft. _
--—----Injection Well: ft. ft -- _—_
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [DStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 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.
4.Date Well(s)Completed: 5/11/22 Well ID# anc
20 It- 50 f`• Shells and Clay MIX
5a.Well Location: 50 ft. 80 ft. Clay
Richard Luettich 80 f`. 100 f`• Clay and Sand Layers
Facility/Owner Name Facility ID#(ifapplicable) 100 f`• 140 " Clay with Sand Layers
319 Lands End Road, Morehead City, 28557 140 f` 175 ft. Clay
Physical Address,City,and Zip 175 It- 204 ft• Limestone
Carteret _635615627663000 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
34' 3' 37" N 760 48' 49 w 17ya 05/25/2022
6.Is(are)the well(s)JMPermanent or Temporary Signature of Certified Well Co actor Date
By signing this form,I hereby cerlifi,that die well(.$)was(were)constructed in accordance
7.Is this a repair to an existing well: QIYes or [3No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Nell Construction Standards and that a
Ifthis is a repair,fill out known well construction injornnation and explain the nature ofthe copy ofthis record has been provided to the well owner.
repair under#11 renrarkr section or on the back ofthis jonn.
23.Site diagram or additional well details: ®p�
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page'to provide q,'tf�tjo a we i s or)well
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells It
construction details. You may also attach additional pages Nee ssry. y I
drilled: SUBMITTAL INSTRUCTIONS JUN 5 2022
9.Total well depth below land surface: 204 (ft-) 24a. For All Wells: Submit this form within 30 S �etyton of well
For umlliple wells list all depths if diJjerent(example-3 tt200'and 2 a 100') construction to the following:
10.Static water level below to of casing: Processing ,r1�J�li
p g: 3O (ft.) Division of Water Resources,Information Processing nit,
Ifwaler level is above casing,use"1" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8 (in.) 24b.For Iniection Wells: In addition to,sending the form to the address in 24a
Mud Rota above,also submit one copy of this form within 30 days of completion of well
12.Well construction method 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) 25 Method of test: Air Lift 24c. For Water SuyPIV&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 lb 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