GW1-2022-09162_Well Construction - GW1_20220930

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1. Well Contractor Information:
Sean Cropsey 14:=Wi1tiERZONESm 'f ;, /.
Well Contractor Name FROM TO DESCRIPTION
70 ft. ft. Limestone
2485 100 ft• 110 "* Sand
NC Well Contractor Certification Number j5X0UT,ERICAtSniq "ld-ca's-d a '!OR INER ifa licabte � ''
ARM FROM ft TO ft.
t ..METER in THICKNESS MATERIAL
Company Name
16IN1!IER!GASINCs�ORIT`,t7BING eofheim"a'l c7iiited"loo ,, - ,VAP
2.Well Construction Permit#: EHWP-2022-00035 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Coun(V,State,Variance,etc.) +1 fL ft. in'
C H S A 0 PVC
3.Well Use(check well use): ft. ft. in.
Ole �F V lr
Water Supply Well: fa7rS(�REE q"
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public 90 ft. 110 ft i" 10 slot CH 40 PVC
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in,
Industrial/Commercial Residential Water Supply(shared) �Tg{GROUT
Irri anon FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft' Bentonite Chips Poured 14 ba s
Monitoring ®Recovery ft. ft.
Injection Well: ft.
Aquifer Recharge Groundwater Remediation D/ ft.
I9.riSAND/GRA�\T ,AGKi if;a licatile"""
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage ft. 110 ft. #2 Gravel Poured
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.4DRIUDING )(3 Mach addiuona`t heetsif=necessarv'
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/mck e, rain size,etc.
0 ft. 20 fL cia 10ght gray to dark
4.Date Well(s)Completed: 09/19/2022 Well ID# 20 fL 40 fLSand and Clay Layers
5a.Well Location: 40 ft. 70 ft. Clay with Sand Layers
Kevin Vanek 70fL 00 fL Limstone andn layers
Facility/Owner Name Facility ID#(ifapplicable) 100 fL 110 ft• Sand med and fine
169 Hardison Road Holly Ridge 28445 ft. ft.
Physical Address,City,and Zip ft. ft. a�w T`w ;•� .�
Onslow z1. 141n1t1zs _. ,V
424704722081
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: {flw: +- 1 r`` 'H"' Ur':'
340 29' 19" N 770 30' 56" W ``!V"`i a3
�� 09/23/2022
6.Is(are)the well(s) Permanent or Temporary Signature of Certified Well Con for 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: Yes or ®No with 15A NC'AC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards 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 tinder#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-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: 110 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'mtd 2@100') construction to the following:
10.Static water level below top of casing: 20 (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
1
13a.Yield(gpm) gp Air Lift
25 n1 Method of test: 24c. For Water Supply& Iniection'i 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 Ib completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016