GW1-2022-05991_Well Construction - GW1_20220617

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: Print Form
1.Well Contractor Information:
Sean Cropsey 14.WATERZONES
Well Contractor Name FROM TO I DESCRIPTION
2485-A 125 ft. 150 ft Sandstone(Pee Dee)
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 ft. 128 ft. 4 tin. I Sch 40 PVC
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: OSWPWP-21-0118 FROM TO I DIAMETER THICKNESS I MATERIAL
List all applicable well construction 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
__Agricultural OMunicipal/Public 127 ft. 147 ft. 2 in.
10 Sch 40 PVC
Geothermal(Heating/Cooling Supply) EfResidential Water Supply(single) fI. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
E
Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
on-Water Supply Well: 0 ft. 27 ft. bentonite chips Poured 1S Bags
Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery [ISalinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. rL
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary
RFROM TO DESCRIPTION color,hardness,soiVmck e, rain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) Q tt pp ft. Clay
4.Date Well(s)Completed: 10/07/2021 Well ID# 20 ft- 401 Shells and gray clay
Sa.Well Location:
40 ft 60 ft- Sand -medium and fine
Delores Meyers 601t• 80 ft- Sand-medium and fine,some rock
Facility/Owner Name Facility ID#(ifapplicable) 80 ft. 100 ft- Gray clay, rock layers (limestone)
1937 Gordon Acres Drive Wilmington, NC 28411 100ft• 125ft• Gray clay and rd'c
Physical Address,City,and Zip 125 ft. 150ft• sandstone °
New Hanover R04300-003-026-025 21.REMARKS
County Parcel Identification No.(PIN) No major limestone layers
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
rotr,iwa lµ J O{LVJ
(if well field,one]at/long is sufficient) VNI
22.Certification:
34'16'24.96" N 77050'25.35 W �a.Q,'�p (�e� 10/19/2021
6.Is(are)the well(s)oPermanent or OTemporary Signature of Certified Well Con ctor Date
By signing this form,I hereby certify that the irell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ©IYes or JDNo with 15A NC'AC 02C.0100 or 15A NCAC 02C'.0200 Nell Construction Standards and that a
If this is a repair,full out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of 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-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: 147(f-) 24a. For All Wells: Submit this form within 30 days of completion of well
For mulliple wells list all depths ifdierent(example-3@200'and 2(@,100') construction to the following:
10.Static water level below top of casing: 40(ft.) Division of Water Resources,Information Processing Unit,
/fwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8" - 4" (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method:
Mud Rotary above, also submit one copy of this form within 30 days of completion of well
.e.auger,(�t ,g 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) 30 gpm Method of test: Air Lift 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 It) 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