GW1-2022-08374_Well Construction - GW1_20220519

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells '
1.Well Contractor Information:
Lewis LeFever 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor d ft. ft.
� �
2480 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. I ft. I in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 65 ft. SCh40 pvc
List all applicable well permits(i.e.County,State, Variance,h jection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 65 ft- 96 f`- 2 in. .010 Sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supplv(single) ft. ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 fr. 44 ft- Portland Cem Tremie
Nan-Rater Supply Well:
❑o Monitorinu ❑Recovery 44 f` 50 ft Bentonite Chii Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 50 f`• 96 f`• l*1 Sand Tremie
❑Aquifer Test ❑Stormwacer Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
[]Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIF TION(color•hardness,soit/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
4.Date Well 5-3-22 s)Completed: Well[D#WW - 21 ft. ft.
ft. ft.
5a.Well Location: ft. ft.
General Electric Company ft. ft. r`-
FacilityiOwner Name Facility ID#(if applicable) ft.
Castle Hayne Road, Wilmington ft. ft.
Physical Address,City,and Zip
21.REMARKS
New Hanover = °:4'.•; i;i' i'i
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
34.330891 N -77.934019 W6.,V_�
S4g ature ofCe,tifiJdVcl1 Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certify that the ire//(s)Bras(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Consiruciion Standards and that a
7.Is this a repair to an existing well: ❑Yes or �No copy oJ'this record has been prorided to the well owner.
1J'1his is a repair,Jill out known ire//construction imtorination and explain the nature of the
repair trader=21 remarks section or on the back of'11is form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
1construction details. You may also attach additional ages if necessary.
.
S.Number of wells constructed. y pages ry
For nnihiple h4ection or non-waler supply wells ONLY with the same construction,you can
submit oneforin. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 96 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For nnihi/e ire/Ls list all depths t'di Brent(example-3 r 00'and 2 e 100') construction to the following:
p p III p � @
10.Static water level below top of casing: Unknown (ft) Division of Water Resources,Information Processing Unit,
((water level is abore casing,use" " 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
12�i Mud Rotary 24aabove, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.aueer,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Nlail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply&Injection Wells:
Also submit one copy of this fonn within 30 days of completion of
136.Disinfection type: Amount: well construction to the county health department of the county where
constructed. i
Form GW-I North Carolina Department orEnvironment and Natural Resources-Division of Water Resources Revised August 2013,