GW1-2022-09930_Well Construction - GW1_20221031

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
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Rawlins Clarke IV 14.WATER ZONE
S
FROM TO DESCRIPTION
Well Contractor Name
NCWC 4234-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for muld-cased wells OR LINER B a Hcable
Redox Tech FROM TO DIAMETER THICKNESS MATERIAL
in.
Company Name 16.INNER CASING OR TUBING !eothermal closed-lao
2.Well Construction Permit#: site of release FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.)
ft. ft. �•
ft. ft. in.3.Well Use(check well use):
17.SCREEN
Water Supply Well:
FROM TO I DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 30 ft' 25 ft 1�•
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) It 30
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation []Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 22 tt. surface ft.
CJMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
[]Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 30 it. 24 rt sand poured
❑Experimental Technology ❑Subsidence Control ft. ft.
[:]Geothermal(Closed Loop) ❑Tracer 20.DRELLING LOG attach additional sheets if necessa
FROM TO DESCRIPTION color,hardness,soiUrock e, in size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
10/14/2022
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location:
S&R Packageing & Crating
Facility/Owner Name Facility ID#(ifaPPltcablc)
4fftt ;�4ftt,
602 Sunnyvale Dr., Wilmington 28412
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rt. rt. ►n;tt;;�;,.,;,.
Physical Address,City,and Zip
New Hanover 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufHcicnt) 22. r [cation:
N W
tgnaturc of ertificd Well Contractor Date
6.Is(are)the well(s): aPermanent or ❑Temporary
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 0N0 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the 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 construction info
(add'See Over'in Remarks Box).You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 30 (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@I00�
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 00 Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use
325 24b.For Injection Wells:COPY)to DWR,Underground Injection Control(IUC)
.
11.Borehole diameter: (in.) Program, 1636 MSC,Raleigh,NC 27699-1636
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12.Wellconstruction method: 9er
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells Droducin z over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
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_r r..,,;.,..,.. ntai niiality.Division of Water Resources Revised 6-6-2018