GW1-2022-06009_Well Construction - GW1_20220615

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: RECEIVE®
Sean Cropsey i 14.WATER ZONES
Well Contractor Name , FROM TO DESCRIPTION
2485-A 42 fl. 62 ft Limestone
ft &NC Well Contractor Certification Number NO' 0 Q/DWR
CAI 1tra+office fiCe 15.OUTER CASING for mulfl-cased wells OR LINER if a livable
Applied Resource Management, PC FROM TO DIAMETER THICKNESS MATERIAL
Company Name +1 fA 42 f" 4 1° SCH40 PVC
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: EHWP-702-2022 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. ft. in.
3.Well Use(check well use): f, ft, in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
_ Agricultural OMunicipaUPublic 0 ft. 20 ft. 4 1°' 010 SCH40 PVC
( Geothermal(Heating/Cooling Supply) CRResidential Water Supply(single) ft. ft. ;n
IndustriaUCommercial DResidential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 20 fL Bentonite Poured
Monitoring DRecovery ft. fL
Injection Well:
ft. ft
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
3 Aquifer Storage and Recovery I—!Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E)Stormwater Drainage 40 ft 62 ft' #2 Sand Poured
Experimental Technology D Subsidence Control ft. ft.
Geothermal(Closed Loop) DI Tracer 20.DRELLING LOG.attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
0 f`, 20 ft. ClaV, sand la ers
4.Date Well(s)Completed: 2/7/22 Well ID# 20 fL 30 ft. Sand wood some clay
5a.Well Location: 30 ft. 35 ft. Sand and clay
AnneLena Mattison 35 ft 62 & Limestone and sandy lime one
Facility/Owner Name Facility ID#(if applicable) ft. ft.
9429 NC HWY 210 Hampstead, NC 28443 f° f`. ,�, �.,_
Physical Address,City,and Zip T
ft. ft. �.� ��'� �. ",
Pender 3255-84-0583-0000 21.REMARKS
9
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: 0S IM 61 P PTT 'P`0,011l
342631 N 77 48 49 W
"t, a 2/14/22
6.Is(are)the well(s) 1�1Permanent or DTemporary Signature of Certified Well Co actor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QIYes or CRNo with 15A NCAC 02C.0100 or 15A 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 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 I 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: 62 (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: 12 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: $ (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
Rotary Mud Rota above,also submit one copy of this form within 30 days of completion of well
(Le Well construction method: construction to the following:
(Le.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: Airlift 24c.For Water Sunaiv&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: 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