GW1-2022-05794_Well Construction - GW1_20220615

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: RECEIVED
Derek Sweeting 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 2022
4557-A 103 ft 138 ft Castle Ha ne
NC DEQ/DWI ft. ft
NC Well Contractor Certification Number Central Office 15.OUTER CASING for multi-cased wells OR LINER if a livable
Applied Resource Management, PC FROM TO DIAMETER THICKNESS MATERIAL
PP g 0 ft. 118 ft 4 in. SCH40 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: EWP-2022-00016 FROM I TO DIAMETER I 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
pp y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public 118 ft. 138 ft- 4 in. 20 SCH40 PVC
Geothermal(Heating/Cooling Supply) EDResidential Water Supply(single) ft ft in.
Industrial/Commercial DResidential Water Supply(shared) 78.GROUT
IIrI ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non Water Supply Well: 0 ft 115 ft Bentonite Pour&1,050
Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge n Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
F Aquifer Storage and Recovery Dli Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage 138 ft- 115 ft- Sand Pour
Experimental Technology Subsidence Control ft ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
F Geothermal(Heating/Cooling Return) F Other(explain under 421 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type rain size,etc.
0 ft 10 & Brown topsoil
4.Date Well(s)Completed: 4/25/2022 Well ID# 10 & 75 & Silty gray clay(soft)
5a.Well Location: 75 ft 103 & Gray clay
James Parran 103 ft 120 ft White hard limestone
Facility/Owner Name Facility ID#(if applicable) 120 ft 138 ft Soft decayed limestone
526 Steadfast Way Jacksonville, NC 28540 It. ft.
Physical Address,City,and Zip ft ft
Onslow 434402555476 21.REMalucs �
County Parcel Identification No.(PIN) t7 U ' E'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
3441 22.393 N 77 31 1.938 W
Da&0,019 �5'uyaa t�; �1aJCs,: Q� Q22
6.Is(are)the well(s)QPermanent or l._!'Temporary Signature of Certified Well Contrac - Date
By signing this form,1 hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or EgNo with 15A NCAC 02C.0100 or I5A 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 tinder 921 remarks section or on the back of ibis 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: 138 (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: 35 (ft.) Division of Water Resources,Information Processing Unit,
Ijwater Jerel is above casing,use"+" 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
u
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) 30 Method of test: Air 24c.For Water Supply&Iniectiori 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: 20% 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