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Home My WebLink AboutGW1--06456_Well Construction - GW1_20231002 . !Print Form WELL CONSTRUCTION RECORD(GW-11 ' For Internal Use Only: • • I.Well Contractor Information: i • • , ; • :.• :Sean Cropsey . , : ' .••• .•• . 14.WATER ZONES i : - ' _ Well Contractor Name •• FR011I TO DESCRIPTION' ; 2485=A' - • • : '110. ft ,140fL . .. ' • :. • it • fI . ! 1 NC Well Contractor CenificationNumber •- 15.OUTER'CASING(for multi-casedfn ells)OR LINER(if ap licable) • Applied ReSollrce•Managerrlent •FROM TO DIAMETER THICKNESS MATERIAL " - • CampadyName; +1 - ft'. •1 1 0-ft. .. . • i•in. - • - • • 16.INNER CASING OR TUBING(geothermal closed-loop) ' . •2.Well Construction Permit#: . •• -• •• •• FROM •TO ..• DIAMETER' THICKNESS MATERIAL - • - 'List all applicable well eonsmtctlon permits(i.e.(yC County.State,Yartancr etc.) ft • f0. • ''' In. • • • . 3:Well Use(check well use): ft.• ft. in • • • tiny• Water'Supply Wei1: • 17.SCREEN • • FROM TO • DIAMETER' SLOT SIZE' THICKNESS •MATERIAL' , A cultural''. Mtlnici aVPublic' fL' fc in O t D p 110 - 140 4. 20.Slot. Sch•40: 'PVC.' :' . • •• OGeothemual(Heating/Cooling Supply) ,�J Residential Water Supply(single) : • . ft. • •• ft. in. •' ' Industrial/Commercial ' Residential Water Supply(shared) ' 18.GROUT' . ' • IiIrrigation •- • FROh7 TO MATERIAL EMPLACEMETTMEllIon&AMOUNT^• '• • • Non-WaterSupply Well: : 0 it' : 70 ft. Bentonite Poured-35 bags.': : ; • DMonitoring . - --0Recovery _- ._• -. - - - -fy --. -.-ft.- . . . --- - . Injection Weil: . ' ' ., ft 'jAquifer Recharge ' • . • ' [• Groundwater Reniediation• - • ' '' • • 19.SAND/GRAVEL:PACK(if applicable) , . Aquifer.Storage and Recovery • 0 Salinity Barrier FROM To MATERIAL.• •• EMPLACEMENT ME HOD " • Aquifer Test •• DStorrnwaterDrainage.. : • 100 rt.. .140.. it'_ :#2 Gravel • '. • Poured • Experimental Technology OSubsidence Control , tt rr • . • • Geothermal(Closed Loop) nTracer 20.DRILLING LOG(attach.addilional sheets if necessary) Geothermal(Heating/Cooling Return) Other(explain under 421 Remarks) FROM TO DESCRIPTION(color,hardness soillrocktrpa crass size;ale.) 0.". . •10 .fa Red'clay • . , • •.• • . • 9/20/2023 fL • ft. 4.Da'te Wells)Completed: well m# 1.0• 40 Med sands Organics': •• • . • - •-Sa.WeliLoca iori: •• ,' 40 f1'• - 95 1`- Clay'with.gray•stone rode layers• • • Matt Grace' . -95.1`• • 130 f` Med sands"to'clay layers with•shells.• • Facility/Owner Name• . . Facility 100(if applicable) 130 f` •' 140 ft. Shells•to clay 1.590 Bissette,Lane,Ayden.NC 28513 .. ft. . • .ft. I. • Physical Address,City,and Zip fa ft. • • . Pitt County • 88080 • ' • 21.REMARKS i":4 6 �+•i 'i. r- . County •• Parcel ldebtification.No:(PIN)• •• •• • •• ' 5b.•Latitude and longitude in degrees/minutes/seconds or decimal degrees: ' .• U • 1� 2��3 : / (if well field,oue lot/long is sufficient) • ' 22.Certification: a ;i,•- Ij ; i1f `� 35 25t.15,r. N 77 21' 58" w !' ►r., ;..,. ,, �. • . ., . �¢a •G°`'w'=912�2/2023. 6.ls(are)the well(s)>�Permanent or DTemporery •• • Signature of Certified Well Con etor,• Date •• • .. - By signing this form,I hereby cer0..thot the trell(s)was(were)constructed in accordance •7.'ls this a repairtti an existing well: ")Yes. or EiNo with 1SA NCAC 02C.0100 or 154 NCAC 02C;0200 IVell Consiructoti Standards and that a - If this is a repot!',Jill out known well construction Information and explain the native of the copy of this record has beer;provided to the well owner. • repair under 021 remarks section or on the back oftldsfoim. 23.Site diagram or additional well details: 8.For Geoprohe/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: : 140' - (ft.) 24a.For MI Wells: Submit this form Within 30 days of completion of well ' For multiple wells list all depths ifdifferent(example-3@200'and 2@l00) construction to the.following: • 10.Static water level below top of casing: • 15 (ft.) Division of Water Resources,Information Processing•Unit, •• , Ifwater level is above casing,use•'+" - 1617 Mail Servi fe Center,Raleigh,NC 27699-1617 11.Borehole diameter: 8 (in.) 24b.For Inieetioa 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.constructian Method: Mud Rotary construction.to the following: (i.e:auger,missy,cable,direct push,etc.) - i . Division bi Water Resources,Underground Injection Control Program,, FOR WATER SUPPLY WELLS ONLY; 1636 Mail Seniee Center,Raleigh,NC 27699-1636 i { 13a.Yield(gpm)_25 Method of test: Air lift • • 24c.For Water Supply&infection Wells: In•addition to sending the•form to , the address(es) above, also subinit one copy of this form within 30 slays-cif I3b.•Disinfection type: HtH Amount: 1 lb. • completion of well construction to the county health department of the county • . - where constructed. I Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016'