GW1-2023-01491_Well Construction - GW1_20230209

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Corey D. Futral 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
4330-B
ft. ft.
NC Well Contractor Certification Numb ' 15.OUTER CASING for ells if a ticable
CATLIN Engineers and Scientists FROM TO DIAMETER THICKNOR LINER ESS MATERIAL
rt. ft. in.
Company Name
16.INNER CASING OR TUBING tiEcotbermal closed-loop)
2.Well Construction Permit#: NA FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.111C,Counrv,State,Variance,etc.) +1 ft. ft. 1 1° Sch 40 PVC
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
PPY FROM TO DIAM ET F:N SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic 15 ft. 25 ft. 1 in. 0.010 Sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wells>100,000 GPD FROM TO MATERLAI. EMPLACEMENT METHOD&AMOUNT
Non-NN ater Suppy fell: 0 ft• 2 ft• Benseal Surface Pour
InMonitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO NI ATERLNL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 2 ft. 25 ft. #2 Medium Sand Surface Pour
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM ft. To rt. DES(Ri 11110%(color,hardness,soiVrock type,Crain size,etc.
4.Date Well(s)Completed: 1/17/2023 ell ma TMW-20230117 ft. ft.
ft. ft.
5a.NNell Location: _
Geosyntec NA ° f`
Facility/Owner Name Facility ID#(if applicable)
2830 US Hwy 421, Wilmington, 28401
Physical Address,City,and Zip ft. ft.
New Hanover NA 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 sufficient) 22.Certification:
34.277795 N -77.958630 W ( `J z
2/10/2023
6.Is(are)the well(s): ❑Permanent or InTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constricted in accordance with
7.Is this a repair to an existing well: ❑Yes or 8No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 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 g2l 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
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 25.0 (ft.)
For multiple wells list all depths if different(example-3@200'and 2@100') Submit this GW-1 within 30 days of well Completion per the following:
22.71 24s. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level.below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use•'-•'
11.Borehole diameter: 4.25 fin.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: D I re ct P u S h
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 roducin over 100 000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,N 27699-161 l
13s.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018