GW1-2022-06421_Well Construction - GW1_20220706

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Sean Cropsey 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2485 - A 175 f`• 204 f`. Limestone
rt. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
ARM FROM TO UWMETER THICKNESS MATERIAL
0 f` 184 fit- 4 in. I SCH 401 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 265523-2 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.I/1C,County.State,Variance,etc•) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Rater Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public 184 ffi" 204 f" 4 in' 10 SCH 40 PVC
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft in.
Industrial/Commercial 13Residential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft- Bentonite Chips Poured 29.Bags
Monitoring _ __ EIRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery [I Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology 13Subsidence Control ft. ft.
Geothermal(Closed Loop) OITracer 20.DRILLING LOG attach additional sheets if necessary
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grain size etc.
0 ft. 20 ft. and
4.Date Well(s)Completed: 5/1 1/22 Well ID# 20 f`• 50 ft. Shells and Clay MIX
5a.Well Location: 50 f`, 80 ft. Clay
Richard Luettich 80 ft. 100 f`. Clav and Sand Layers
Facility/Owner Name Facility ID#(if applicable) 100 fL 140 f`' Clay with Sand Layers
319 Lands End Road, Morehead City, 28557 140 f` 175 ft' Clay
Physical Address,City,and Zip 175 ft- 204 fL Limestone R°°m
Carteret 635615627663000 21.REMARKS
County Parcel Identification No.(PIN) JUL 0 ' 2022
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: InfofiYt^icin Prt?C,SPs-ging Unk
34' 3' 37" N 760 48' 49 w Dt•`VQ%S0G
Q �u�ur�_ 05/25/2022
6.Is(are)the well(s)IzPermanent or OTemporary Signature of Certified Well Co actor Date
_ Hy signing this farm,I hereby certifi,dot the wells)was(were)consinicied in accordance
7.is this a repair to an existing well: 13Yes or [3No with 15A NC'AC 02C.0100 or 15A A'CA C 02C.0200 lVell Construction Standards and that a
/f 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 i:21 remarks section or on the hack 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-I 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: 204 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For wrthiple wells list all depths ifdi(jerent(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,
/fwater level is above casing,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
Mud Rotary above, also submit one copy of this form within 30 days of completion of well
u oa
12.Well construction method: ry construction to the following:
(i.e.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: 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 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