GW1-2022-08743_Well Construction - GW1_20220823

Print Form
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1. Well Contractor Information:
Sean Cropsey 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
165 f. 195f- Sandstone
2485 - A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
Applied Resource Management FROM TO DIAMETER THICKNESS MATERIAL
Company Name �V� 0 ft' I 175t' 4 in Sch 401 PVC
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e. UC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public 175 ft. 195 I'L 2 in. 20 Sch 40 PVC
Geothermal(Heating/Cooling Supply) [3IResidential Water Supply(single) ft B, in.
PIIndustrial/Commercial [3IResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft* gentonite chips Poured 15 bags
Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
®IAquifer Storage and Recovery Dl Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 01 Stormwater Drainage ft. ft.
Experimental Technology [:]I Subsidence Control ft. ft.
bGeothermal(Closed Loop) [:IITraeer 20.DRILLING LOG attach additional sheets if necessary)
so
Geothermal(Heating Cooling Return)) FROM TO DESCRIPTION(color,hardness, il/rock e,grain size,etc.Other(explain under#21 Remarks) 0 ft. 10 ft* Clay
4.Date Well(s)Completed: 7/22/2022 Well ID# 10 ft. 20 ft. Sand and shells
5a.Well Location: 20 ft- 40 ft' Sand and clay
Gary Olson 40 ft. 60 ft. Shells and sand
Facility/Owner Name Facility ID#(ifapplicable) 60 ft. 125 ft' Limestone
2322 Scotts Hill Loop Road 125 f- 165 ft- Mud and Mud rock
Physical Address,City,and Zip 165 ft- 195 ft. Sandstone
Pender 3280-25-0309-0000 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
34 18' 27" N 77 44' 6" W �'� 7/22/2022
6.Is(are)the well(s):®IPermanent or [3ITemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3IYes or ®No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature of the copy ofthis record has been provided to the well owner.
repair under 421 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 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: 195 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3CJ)200'and 2@100') construction to the following:
10.Static water level below top of casing: 25 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: $ (in.) 24b. For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: Mud Rotary above, also submit one copy of this form within 30 days of completion of well
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) 40 gpm Method of test: Air Lift 24c. For Water Supply& Iniection 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: Amount: completion of well construction to the 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