GW1-2022-07021_Well Construction - GW1_20220726

i
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Rawlins E Clarke IV 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
NCWC 4234-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a licable
Redox Tech, LLC FROM TO D WNIETER THICKNESS MATERIAL
ft. ft. in.
Company Name 16.INNER CASING OR TUBING eothermal closed-lao
W10800554 FROM TO DLIMETER THIC[GNESS MATERWL
2.Well Construction Permit#: ft ft. in.
List all applicable well construction permits(i.e.U1C,County,Stare,Parlance,etc.)
ft. ft. in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIA+M'IETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fL ft
❑Industrial/Commercial ❑Residential Water Supply(shared) 18,GROUT
❑We11s>10Q,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation ft, ft.
Non-Water Supply Well:
❑Monitoring ❑Recovery ft. ft.
Injection Well: fL ft.
❑A uifer Recharge IlGroundwater Remediation
q 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FRo,r[ To
MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology
❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soiUrock VPe.�nin sire,etc.)
❑Geothermal(Heating/Cooling Return) El Other(explain under#21 Remarks) g• ft.
7/6/22 OP-3,DP-3A.OP-0.DP-0A,OP-4B ft. ft•
4.Date Well(s)Completed: Well ID#
DP-5,DP-5A.DP-5.DP-6&OP-68.DP-7 ft. ft.
5a.Well Location: ft -ft.
Molpus Woodland ft, ft.
Facility/Owner Name Facility[DO(if applicable)
ft.
Town Creek Rd NE, Leland, NC 28451 ft. M��Irl
ft. ft.
Physical Address,City,and Zip
06800030 21.REMARKS
Brunswick y
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22 CertiAifiedell
►"Q/BOG 9 Ufa
(ifwell field,one lat/long is sufficient)
340 11' 6.1" N 780 12' 7.7" W 7/21/2022
Signature oractor Date
6.Is(are)the well(s): ❑Permanent or 19Temporary
By signing dtis-form,!hereby certify that the u•e!!(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 81No 15A NCAC 02C.0100 or 15A VCAC 03C-.0200 6Vell Constniction Standards and that a copy
If this is a repair fill our/nvo+on++•ell con.rtnrction information and erpinin the nature gfthe
of this record has been provided to the well owner.
repair under=1!remarks section or on the back of thi,sJortm' 23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells
drilled:11 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 6@12'; 4@10'; 1 @9' (ft.) Submit this GW-I within 30 days of.well completion per the following:
For multiple wells list all depths if d fferenl(example-3@?00'and'a100')
668 24a. For All Wells: Original form to Division of Water Resources (DWR),
.
10.Static water level below top of casing: (fi,) Information Processing Unit,1617 NISC,Raleigh,NC 27699-1617
water level is above caring,rise
24b. For Infection Wells: Copy;to DWR, Underground Injection Control(IUC)
11.Borehole diameter: �'S (1°) Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:
Direct Push 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health departi-nWt of the county where Installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producint over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
North Carolina Department of Environmental Quality-Division of Water Resources
Revised 6-6-'_018
Form G W-I