GW1-2022-06887_Well Construction - GW1_20220718

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Sean Cropsey 14.WATER ZONES
' i
Well Contractor Name FROM TO DESCRIPTION
90 IL 110 f`' Sandstone
2485 - A ft. ft.
NC well Contractor Certification Number 15.OUTER CASING for multi-cased wells,TO LINER(if a l oble)
ARM FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 f`' 50 f`• 8 '°• Sch 40. PVC
16.INNER CASING OR TUBING(eotliermal closed-loop)
2•Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable ivell construction permits(i.e.WC,County.State,Variance.etc.) ♦ ' ft. 90 ft. 4 "' Seh 40
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM .TO DIAMETER SLOTSIZE THICKNESS MATERIA
Agricultural [IMunicipal/Public 90 ft. 110 f`' 4 10 Slot SCh 40 PVC
Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL, EMPLACEMENT METHOD&AMOUNT
- I Non-R%atcr Supph Well O ft, 74 ft gentonite Chips POured.22 bags
oklonitoring --QlRecovey ft. ft.
Injection Well: '-
ft. ft
Aquifer Recharge QlGroundwater Remediation
I9.SAND/GRAVELPACK(if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage 110 f`' 74 '`' #2 Gravel Poured
Experimental Technology QlSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG tattach additional sheets if necessary
Geothermal(Heating/Cooling Return) OOrer(explain under#21 Remarks) FROM To DESCRIPTION'color,hardness,soiUrock e: rain size,etc.
0 . ft, 20 ft Oran de Clay
4.Date Well(s)Completed: 6/28/22 Well]DO 20 ft. f`' Sand and Shells
5a.Well Location: m
ft. 35 ft. Gray day and shells
Bryan Humphrey 35 4 f`' Limestone- Open hole
Facility/Owner Name Facility lD#(if applicable) 45
ft. 50 ft Sand,:
2715 Columbia Ave, Wilmington 28403 so f`. 55 f` Limestone
Physical Address,City,and Zip 55 f`' 90 f' Gray clay and mudroek
New Hanover R05412-002-009-000 21.REMARKS
County Parcel Identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: juL
(if well field,one lat/long is sufficient) 22.Certification:
34013' 41" N 770 64' 35" W I M2 q 'eXi
1
6.Is(are)the well(s)JDPermanent or DTemporary Si mature of Certified Well Con actor Y XV-Civd1 r
By signing dris farm,I herebv certifi,that the well(f)was(here)-constructed in accordance
7.is this a repair to an existing well: Yes or [@No dint 15A NC•AC•02C.0100 or 15A A'CAC 02C.0200 IFell Construction Standards and that a
1f this is a repair,fill out known ivell consirucdon information and explain the nrifure aJ'!he copy of this record has been provided to the well ou-ner.
repair Larder x21 rentarla 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-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: 110 (ft.) 24a. For All Wells: Submit,this form within 30 days of completion of well
1-or multiple vveils list all depdns J dierent(example-3 r1 200 and 2 tr,100') construction to the following:
I
10.Static water level below top of casing: 20 (ft.) Division of Water Resour'cei,Information Processing Unit,
If water lerel is above casing,rive"-•' 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 Rota above,also submit one copy of this form %ithin 30 days of completion of well
12.Nell construction method: Rotary construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,11nderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(-,pm) 50 Method of test: Air Lift 24c. For Water Supply& ]niectialn Wells: It,addition to sending the form to
the address(es) above, also submiti one copy of this form %tithin 30 days of
13b.Disinfection type: HTH Amount: completion of well construction to�thel 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