GW1--03950_Well Construction - GW1_20230612

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rT Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1. Well Contractor Informal!art:
Sean Cropsey 14,%VATER ZONES
Well Contractor Name FROhI TO DESCRIPTION
ka 130 IL 160 11 Sandstone
2485 -A I 1� fL &
NC1Vell ContractoeCcrtifcationNumber IJ IV 1 2 M3 15.OUTER CASING'far multi-cased well§ OR LINER ifn ]icable
Applied Resource Management,,. FROh1 TO DL\MEiER THfCIOVFSS MATERIAL
pp 9 _ 7r-. �P� �l:na }1 fL 130 ft. 4 im Sch 40 PVC
Company Name t1' c
pp�+���'' 16,INNER CASING OR TUBING °eothermal closed-loop)
2.Well Construction Permit fl: PWS2022- 1 00704 FROM TO I DLIUETER I THICKNESS I hIATERIAL
List all applicable well conrtntulon permits(i.e.UP;,County,State.Variance,etc.) f, fL in.
3.Well Use(check well use): it. & in.
L11' PPY ater Supply Well: 17.SCREEN
FROM TO DUNIEfER SL07SILE THICKNESS hIATERIAL
Agricultural QMunicipal/Public 140 ft 160 fL 4 i- 20 Sch 40 PVC
Geothermal(Heating/Cooling Supply) [Residential Water Supply(single) ft. I ft. lm
Induslrial/Conimercial [Residential Water Supply(shared) 11.GROUT
Irrigation FROM To MATERM xmFLAcFMENTT1E RoD&AMOUNT•
Non-Water Supply Well: 0 (1, 30 I1• Bentonite Poured 24 bags
Mcnitoring ---- ------ - - ORecovery -- — it - — fL- -
injection Well: ft ft
Aquifer Recharge [Groundwater Remediatien
19,SAND/GRAVEL PACK ifa Iicable
Aquifer Storage and Recovery Salinity Barrier FROM To I MATERUL E111PLAC111E ENr hiETHOD
Aquifer Test [StormwatcrDrainage 135 ft, 160 ft. #2 gravel 20 bags - poured
Experimental Technology iDSubsidence Control ft. &
Geothermal(Closed Loop) [Tracer 20.DRILLING LOG attach additional sheets if necessary
FROM TO DESCRn'TION(color.hardaess.soiVrock e. rain sire,etc.
PGeothcrrual(Heating/Cooling Return) Other(explain under 1121 Remarks) FROM
fL 10 11. Hard tan clay
4.Date Well(s)Completed: 3/9/2023 Well IDII 10 11- - 201 Soft ra cla
5a.Well Locations_ 20 It- 30& Sand and:shelis
Clifford Strickland- 30I` 70 fL Gra -cla -and mud rock
Facility/Owner Name Facility lDtl(ifapplieable) 70 fL 90`1-- Sand layers and light gray clay
3953 Avon Rd,-Grimesland, NC 27837 90 rL 13011- Llqhies_qray clay and sand
Physical Address,City,and ZIP 13011• .16011, Conslidated.sand and shells
Pit County 30856 21.REMARKS .
County Parcel identification No.(PIN) Grout was self certified
5b.Latitude and longitude in degrees/minuies/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
35 35' 33" N 77 14' 24" W , a 3/9/2023
6,Is(are)the well(s)oPermanent or [Temporary SiguatureaECcrtifiedWcllContdctor Date
By aign(ng rids form,1 hereby certJ6,that the srell(s)was(were)constructed in accordance
i.IS(iris a repair is an existing well [Yes at- M1Ya with 1 SA NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
1f this'is a repair,fill out!mown well construction!t)formation and explain the nature of the copy oflhtt record has been provided to the well asrner.
repair wider#21 renrarkr section or on the back of Ihls 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 I GW-1 is needed. Indicate TOTALNUMBER ofwclls construction details, You may also attach additional pages if necessary.
drilled; Si_UBMITTAi,INSTRUCTIONS
9.Total well depth below'land surface: 160 A) 24a. For All Wells: Submit this form within 30 days of completion of well
For nudliple wells list all depths ifd!•jferent(exonrple-3@200'and 2@100') construction to the following:
I0.Static water level below top of casing: 40 (ft.) Division of Water Resources,Information Processing Unit,
Ifwaterlevel is above casing,use'•+" 1617 Mail Sen'ice Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8 (in.) 24b.For inlectinn Wells: In addition to sending the form to the address in 24a
Mud Rota above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: Rotary construction to the following:
(i:e.auger,rotary,'cible,diced push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Sen•ice Center,Raleigh,NC 2 769 9-1 63 6
13a.Yield(gpm) 40 Method of test: Air Lift 24c.Fnr Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
131L Disinfection type: HtH Amount: 1 lb. completion of well construction to the county health department of the county
where constructed.
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Form G%V-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22.2016