GW1-2022-06986_Well Construction - GW1_20220725

3
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Irylnn Bautista 14.WATER ZONES.,
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
4504-A
ft. ft.
NC Well Contractor Certification Number d5:OUTER CASING for multi=cased wells OR LINER if a li able
A.C. Schultes of Carolina, Inc. FROhI TO DIAMETER THICKNESS 1IATERLIL
ft. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop),
2.Well Construction Permit#: 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): ft. ft. in.
17.
Sep
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM To MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stonnwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. %
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soittrock e, rain size,eta
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 188 ft- 198 fi- Limestone/Trace of Clay
4.Date Well(s)Completed: 1/25/2021 Well ID# 42 198 ft. 218 ft. Limestone
5a.Well Location: 218 ft' 258 ft. Limestone/Big Shell
U.S. Navy ft. fr. rN
Facility/Owner Name Facility ID#(if applicable) ft. ft.
ft. ft. d ti _
Physical Address,City,and Zip ft. ft. ✓n P
f1A
Craven
21.REMARKS
County Parcel ldentification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Cc 'fication:
433449.48 N 2636229.26 W - _
6.Is(are)the well(s): nPermanent or ❑Temporary Si atone of C011fi.
ell Contracto Date
by signing thishereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo ISA NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,furl out known well construction information and explain the nature of the 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 construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 251 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2 tr 100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
f Static water level below top of casing: 28 (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: 29 (in.) 24b. For Injection Wells:Copy to DWR,Underground Injection Control(NC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rotary
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
659 24hr. pumping Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: HTH Amount: 5 IbS.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018