GW1-2022-09164_Well Construction - GW1_20220930

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
'14.WATER>ZONTC�s3� „<xk
Sean Cropsey
a s s d FROM TO DESCRIPTION
Well Contractor Name
175 f`' 195 ft Sandstone
2485
S F P 3 n 2022 ft. ft.
NC Well Contractor Certification Number 715.OUTER CASWG`fdir'Idtased;iveac`OR=isINERr if A lic`ab'le YZ
ARM In{vf;i u C 1 !^f{ ='s't' •a� Ur"S FROM TO DIAMETER THICKNESS MATERIAL
Company Name `�'� •!ua�� +1
ft. 162 ft. 1 4 in.
46JNNERICASINGtOR':TUBING; eo`thermal'clbsed too + .:.`
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C County,State, Variance,etc.) 155 ft. 175 ft. 2 in-
3.Well Use(check well use): ft. ft. in.
Water Supply Well: r17.vSCREENtr�.*.sue zf, ,m": •a•a�� a ..,
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural [3MunicipaVPublic 175 ft• 195 f .f
t. 2 'n' 10 SCH 40 PVC
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
industrial/Commercial 13Residential Water Supply(shared) :
)I94GROUT.W a: a
Trri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 " 20 ft• Bentonite Chi s Poured 12 baas
Monitoring ®Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
,1 e1VE 9?SA,ND/GRLVP,ACKi if;gp—plieible ` r of f v
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.$DRIliLING±UGGfaf chradditionalsh lif,necessary -^
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,sofl(mck type,gmin size,etc.
ft ft.
Red + Tan Cla
4.Date wells)Completed: 9/14/2022 Well ID# 20 ft 40
tt• Gray Clay _ Sand Shells
5a.Well Location: 40
ft. 5 ft.
Phillip Martin 55f` ftLimestone
Facility/Owner Name Facility ID#(if applicable) ft. 175 ft Dark Clay
661 Hughes Road, Hampstead 28443 175 ft f`• Sandstone
Physical Address.City,and Zip
ft. ft.
21 xREIVIARKS 1." ,. �. ;t-r
Pender 3291-08-0590-0000
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
340 20' 3611 N 770 42' 28" w 09/14/2022
6.Is(are)the well(s)JIPermanent or 13Temporary Signature of Certified Well Contrapbr Date
By signing this.form,1 hereby cert ,that t e wells)was(Here)constructed in accordance
7.Is this a repair to an existing well: 13Yes or Jallo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Lf 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 hack 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
Far multiple wells list all depths ifdii ferent(exanhple-3 a 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: 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) +30 gpm Method of test: Air Lift 24c. For Water SuoDly&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 1b 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