GW1-2022-05871_Well Construction - GW1_20220617

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: Print Form
1.Well Contractor Information:
Sean Crop Sey 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2485-A
130 ft 165 ft-1 Sandstone
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable)
Applied Resource Management FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 1 70 ft. 8 iin. SCh 40 PVC
OSWPWP-21-0152 16.INNER CASING OR TUBING eotherma]closed-loo
2.Well Construction Permit#: FROM TO I DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.ULC,County,State, Variance,etc.) +1 ft. 150 f' 4 nn' I SCh 40 PVC
3.Well Use(check well use); ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) 150 ft 170 ft- 4 in 20 SCh 40 PVC
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 30 ft- Bentonite Poured 19 bags
Monitoring ORecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK ifa licable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage 140 ft. 170 ft- #2 Poured
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) [3Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) 130ther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soittruck type,grain size,etc.)
0 ft. 10 ft- Sand
4.Date Well(s)Completed: 2/3/2022 Well ID# 10 ft. 30 fr• Clay
5a.Well Location: 30ft• 50 ft• Sandshells, some clay
Nicole Garrigan 50 ft' 60 ft- Shells, limestone, hole
Facility/Owner Name Facility ID#(ifapplicable) 60ft• 110 fL Limestone
4050 Chapra Drive, Wilmington, NC 110ft• 130 ft- Mud, -grey clay
Physical Address,City,and Zip 130ft• 165 ft- Sandstone, saridyto mud p�
New Hanover R07106-004-003-000 21.REMARKS
County Parcel identification No.(PIN)
C?ir ti
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �'__ KX1 _Pal I
(ifwell field,one lat/long is sufficient) IT:i ??jsi� tLPI• I s, (��7• ,;v17 UI\
22.Certification:
34 10 1 N 77 53 57 w -Sea 2/3/2022
-.4z, L,2,6�1
6.Is(are)the well(s)OPermanent or [ITemporary Signature of Certified Well Contrac Date
By signing this form,1 hereby certi)5,that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: EIYes or EJNo with 15A NCAC 02C.0100 or I5A NCAC 02C'.0200((tell Construction Standards and that a
1f this is a repair,fill ma known well construction information and explain the nature ofthe copy ojthis record has been provided to the well owner.
repair under#21 remarks section or on the back of this fibrin.
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 ofwells construction details. You may also attach additional pages ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 170(fit•) 24a. For All Wells: Submit this form within 30 days of completion of well
For nn lliple wells list all depths ifdii ferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
Ywater level is above casing,use"+'• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
above,also subunit one copy of this form within 30 days of completion of well
12.Well construction method: Mud Rotary(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 40 Method of test: Airlift 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 lb 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