GW1-2022-09101_Well Construction - GW1_20220926

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Sean Cropsey 14.WATERZONES
Well Contractor Name FROM TO DESCRIPTION
2485-A (t _ , - 260 ft. 295 ft' Shells and Gravel
5;- ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi eased wells OR LINER if a licable
ARM HP �� 2022 FROM TO DIAMETER THICKNESS MATERIAL
Company Name +1 1' 275 ft' 4 in. SCH 40 PVC
r t���{{S`l➢u 1 'i: n ';'.� Or "e 16.INNER CASING OR TUBING eofhermal closed-too
2.Well Construction Permit#: NW22-Obi t tZ is l¢ FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well conslntction permits(i.e.UIC,C'ountv.Stale, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft• I ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public 275 ft- 295 ft' 4 in. 10 SCH 40 PVC
Geothermal(Heating/Cooling Supply) [BResidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irri atlon FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 It- 35 ft' Bentonite Chips Poured-25 Bags
Monitoring DRecovery ft. ft.
- - Injection Well: - - - - - - ft. -- ft.
- - -- -- - - -
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage 270
ft. 295 ft. #2 Gravel Poured 18 bags
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) 13Tracer 20.DRILLINGLOG-attach additional,sheets ifnecessary
Geothermal(Heating/Cooling Return) F30ther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiltrock type,grain sin,etc.
0 ft' 10 ft. Tan Sand(Fine)some clay
4.Date Well(s)Completed: 8/25/2022 Well ID# 10 ft. 30 ft'
Gray Sand Fine
5a.Well Location: 30 ft' 100 ft. Gray Clay-Mud Rock
Gordon Joslyn 100 ft. 140 ft
Facility/Owner Name FacilityID#(if applicable) 140 fL 180 ft' Fine Sand-some gravel-silty clay
160 Wildwood Drive, Oriental 28571 180 f" 260 ft• sticky clay to sandy clay
Physical Address,City,and Zip 260 ft. 295 ft. Medourn Sand with Shells
Pamlico 7409432525 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latdong is sufficient) 22.Certification:
35o 4' 59" N 76' 38' 47" W
_� 8/25/2022
6.Is(are)the well(s)MPermanent or Temporary Signature of Certified Well QKntracto Date
By signing this form,I hereby certifi,that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 1IYes or EJNo with 15A NC•AC 02C.0100 or 15A NC'AC 02C.0200 Ezell Construction.Smndards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy 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 site details or well
construction,only 1 GW-I 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: 295 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For mtuhiple wells list all depths ifdifferent(example-3@200'and 2 ct.100') construction to the following:
10.Static water level below top of casing: 10 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8 (in.) 24b. For Infection Wells: In addition 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: Mud Rotary 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 Sumily&Infection 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.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016