GW1-2022-06002_Well Construction - GW1_20220617

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Sean Cropsey 14.WATERZONES
Well Contractor Name FROM TO DESCRIPTION
2485 -A 162 f`' 182 "' Shell Limestone
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
Company Name +1 ft. 162 l" 4 40 PVC
347083 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction perodts(i.e.U1C,County,Slate,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
i_ Agricultural Municipal/Public fL ft. in
162 182 4 10 40 PVC
Geothermal(Heating/Cooling Supply) IOResidential Water Supply(single) ft. ft. in.
Industrial/Commercial QlResidential Water Supply(shared) 18.GROUT
Irri ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
INon-Water Supply Well: 0 ft. 20 ft' Bentonite Chips Poured-10 bags
Monitoring (Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge [3Groundwater Remediation
19.SANDIGRAVEL PACK(if applicable)
Aquifer Storage and Recovery I®ISalinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test [3StormwaterDrainage 0 ft. 20 ft. #2 Gravel Poured
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiltrock e, rain sin,etc.
0 fr. 10 rt. Clay
4.Date Well(s)Completed:02/14/2022 Well ID# 10 ft. 20 ft• Sand
Sa.Well Location: 20 ft' 30 fL Clay and Shells
Stephanie Smith 30 f`' 80 f`- Shellv,Grey Clay Layers,some sand
Facility/Owner Name Facility ID#(if applicable) 80 ft. 150 f`• Clay,s0fy and hard, stick(
2303 Shore Dr Morehead City 284557 150 ft- 182 ft• Lime Stone
Physical Address,City,and Zip ft. ft.
Carteret 638713241770000 21.REMARKS
County Parcel Identification No.(PiN) JUN 17 20
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: t.,,,•., q
(if well field,one lattlong is sufficient) Jc '�'= 'i I�f,
22.Certification:
340 45' 30" N 76°43'41" W
�� C�4,& � 02/15/2022
6.Is(are)the well(s):R]IPermanent or OTemporary Signature of Certified Well C ntractor Date
By signing this form,I hereby cert fi,that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: rJIYes or ®No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Nell Construction Standards and that a
If this is a repair,fill out known well construction injonuation and explain the nature of the copy of this record has been provided to the well owner.
repair under 921 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: 182 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For i n lliple wells list all depths ifdijjerent(example-3 n 200'mud 2@/00') construction to the following:
10.Static water level below top of casing: 12 (ft.) Division of Water Resources,Information Processing Unit,
If svaler level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8 (in.) 24b. For infection Wells: In addition to sending the form to the address in 24a
12. Mud Rota above, also submit one copy of this form within 30 days of completion of well
(i.e.Well construction method: Rotary.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) 10 Gals Method of test: Air Lift 24c. For Water Supply&Infection 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