GW1-2022-06914_Well Construction - GW1_20220718

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor information:
Sanford Sweeting 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
2082 - A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licahle
ARM FROM TO DIAMETER THICINESS ,IV
ft. It, in.
Company Name
16.INNER CASING OR TLBING(geotliermal closed-loop)
2.Well Construction Permit#: 1989018865A FROM TO DIAMETER I THICKNESS NATERIAL
I_ist all applicable well construction permits(i.e.(71C,C:ountP.State,Variance.etc.) ft. ft.
3.Well Use(check well use): ft. ft.
Water Supply Well: FROM
SCREEN
FROM TO DTAINIETER SLOT SIZE THICKNESS MATERIAL
Agricultural FIMunicipal/Public 55 ft. 75 ft• 4 m. PVC
Geothermal(Heating/Cooling Supply) Residential\4ater Supply(single) ft ft in.'
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT'
irrigation FROM TO MATERLAL EMPLACEMENT METHOD&AhIOUNT
Non-Water Supply Well: 0 ft' 50 ft. Bentonite Chios Poured
t3rMonitoring_ _ .._ —_ __DRecovery ft. ft.
Injection Well: — ft. ft. -
Aquifer Recharge Groundwater Remediation h
19.SAND/GRAVEL.PACK(if applicable),
Aquifer Storage and Recovery [3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage 50 ft. 75 fL #2 Gravel Poured
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary
Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/mck type.Erwin size,etc.
0 ft' 25 ft' Finia Sand, somei
4.Date Wells)Completed: 6/29/2022 Well ID# 25
ft. 75 ft.
5a.Well Location: ft. ft.
Old Fort Golf Course ft. ft. a`- t•�
FacilitylOwner Name Facility lD#(if applicable) ft. ft.
juL
3189 River Road SE, Winnabow 28479 ft. ft. `
Physical Address,City.and Zip ft. ft.
21,REMARKS .tri_i�nR� C°4.C'��+1M
Brunswick 310300559214 '
County Parcel identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: _
(if well field,one lat/long is sufficient) 22.Certification:
340 07' 3118" N 770 58' 59.47" a p S ! 6/29/2022
6.Is(are)the well(s)0Permanent or OTemporary Signature of tified Well Contractor Date
By signing this jorni,LhereEn certii,that the wells)wets(ivere)constructed in accordance
7.Is this:t repair to an existing well: Q!Yes or [@No ivith 15A NC'AC 02C.0100 a•15.4 NCAC 02C.0200 i(ell Construction Standards and that a
Ifthis is a repair,Jill.out knovu well construction information and explain the nature of'!he copy of this recordhas been provided to the well owner.
repair under�21 remarks section or on the back gfthis 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: 75 (ft•) 24a. For All Wells: Submit this form %vithin 30 days of completion of well
For nudtiple ivells list all depths iJ different(example-3@200'met 2 a 100') Construction to the following: 1
10.Static water level below top of casing: 15 (ft.) Division of Water ResourI ej,Information Processing Unit,
ffwaterlevel is above casing.use•'T'. 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 8 (in.) 24b.For Infection Wells: in additilonl to sending the form to the address in 24a
above, also submit one copy of this,form within 30 days of completion of well
12.Well construction method: 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) 10 Method of test: Air Lift 24c.For Water Supply& Iniectio'n 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.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources ' Revised 2-22-2016