GW1-2022-06010_Well Construction - GW1_20220615

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WELL CONSTRUCTION RE!,=f-� GGW�-1) For Internal Use Only:
1.Well Contractor Information:
Sean Cropsey JUN 1 0 2022 14.WATER ZONES
v FROM TO DESCRIPTION
Well Contractor Name
35 ft 65 ft1 Limestone
2485-A NC DEO/DWR 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
+1 ft' 45 ft' 4 in. SCH40 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit#: EHWP-694-2022 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) f, ft in.
3.Well Use(check well use): f, ft in.
Water Supply Well: 17.SCREEN
pp y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ElMunicipal/Public 45 ft 65 ft 4 in. .010 SCH40 PVC
Geothermal(Heating/Cooling Supply) EgResidential Water Supply(single) ft, ft
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Iffl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft Bentonite Poured
Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery D!Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage 43 ft 65 ft #2 Sand Poured
Experimental Technology DSubsidence Control ft. ft.
F Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
C Geothermal(Heating/Cooling Return) 0 Other(explain under 421 Remarks) FROM I TO DESCRIPTION color,hardness,soillrock type rain size,etc.
0 !ft'
20 ft- Clay
4.Date We11(s)Completed: 2/7/22 Well ID# 20 27 ft Wood
5a.Well Location: 27 35 ft. Sand and shells some claAnneLena Mattison 35 62 ft Limestone with sand layers
Facility/Owner Name Facility ID#(if applicable) 62 ft 65 ft Dark Clay
9429 NC HWY 210 Hampstead, NC 28443 ft ft 2 1
Physical Address,City,and Zip ft. ft
Pender 3255-74-6140-0000 21.REMARKS
County Parcel Identification No.(PIN)
Do 1 i'i�'r5'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: R ,
(if well field,one lat/long is sufficient) 22.Certification:
34 26 37 N 77 48 46 W
n',"L � 2/8/22
6.Is(are)the well(s)MPermanent or OTemporary Signature of Certified Well Co actor Date
By signing this form,1 hereby certif},that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or E3No 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 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: 65 (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: 8 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Rotary 12.Well construction method: Mud Rota above,also submit one copy of this form within 30 days of completion of well
(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) 25 Method of test: Airlift 24c.For Water Supply&Injection Wells: hi 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