GW1-2023-02566_Well Construction - GW1_20230410

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: j
Scott Werley 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3344-A 3.5 ft. 7.5 ft.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER lieable)
ECS Southeast, LLP FROM TO DIAMETER THICKNESS MATERIAL
Company Name
ft. I ft. in.
"� 16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit# /y/A FROM TO DIAMETER THICKNESS MATERIAL
List all applicable ivell construction perudts(i.e.U/C,Counov,State, G'ariance,etc.) 0 ft, 2.5 ft. 1 in.
3.Well Use(check well use): ft. ft. I in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ®Municipal/Public 25 ft, 7.5 ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
IndustriaUCommercial Residential Water Supply(shared) 18.GROUT
;Irri ation FROM TO MATERIAL E\IPLACE\IENT METHOD&AMOUNT
Neon-c1Water Supply Well: ft. ft.
Monitoring Recoveryion Well*___. -
--ft
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if a lieable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage 7.5 ft. 2 ft. #2 sand pour
Experimental Technology Subsidence Control 2 ft. 0 tt bentonite pour
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
BFROM TO DESCRIPTION(color,hardness,soilfrock type,grain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
0 tt• 2 ft* Black,very fine grained sandy silt
4.Date Wells 2/21/2023 Well iD#TW-1 &TW-2 ft. 35 ft.
()Completed: 2 Tan motded'with orange fine grained silty sandy clay
5a.Well Location: 3-5 ft 4.5 tt Gray and tan sandy clay
MCAS Cherry Point P-995 4.5 n. 7.5 ft. Gray fine•siltysand z-,
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Cherry Point, NC ft. ft.
Physical Address,City,and Zip t't. t't.
Craven NA 21.REMARKS
yi J
County Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) ication:
34.88361 N -76.889416 W
6.Is(are)the well(s)oPermanent or igTemporary Signature ofCertiried We ntm or Date
By signing this formn, i herehv ertiify that the well(s)ivas(were)constructed in accordance
7.Is this a repair to an existing well: nYes or x)No with 15A NCAC 02C.0100 at-15A NCAC 02C.0200 Well Construction Standards and that a
ff this-is-a repair fill out known well construction itFforntation and erplain the nature of the copy of thisrecord has-been provided to the well owner. -
repair tinder#21 remarks section or on the back ofthis 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:TNOtz>
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 7.5 (t't.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifili erent(example-Sea 200'and 2(rg100D construction to the following:
10.Static water level below top of casing: 3.5 (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: 3.25 (in.) 24b.For infection Wells: In addition to sending the form to the address in 24a
hand auger above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: 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) Method of test: 24c. For Water Supply& Iniection 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: Amount: 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
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