GW1-2021-00449_Well Construction - GW1_20210726

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WELL CONSTRUCTION RE •RD ,
NORTH CAROLINA
EnWronmental Quullty
•rm GW-1 Well Constructon Electronic •
North Carolina Department of En\Aronmental Quality
April 1,2021
Submission ID#
G W 1-2021-00449
Are you submitting a printed form?* r Yes
r No
CONTACT INFORMATION
.........................................................................................................................
Contact Name* Email Address*
Justin Nixon [e-mail]
Is this a revision to the form you have previously submitted?
r Yes r No
WELL CONSTRUCTION INFORMATION
..................................................................................................................................................................................................................... ...............................................................................................................................................................................................................................
1.Who is installing these wells?*
r Owner r Well Contractor
1.Well Contractor Information:
Certiticate# Cert Level First Name Last Name Company Name
4265 A JUSTIN NIXON MAGETTE WELL&PUMP CO., INC.
2.Well Construction Permit#:
List all applicable well construction permits(i.e.Monitoring Wells,UIC,County,CCPCUA,etc.)
What type of well is this?* r Injection Well r Non-Water Supply Well
r Water Supply Well(includes irrigation wells)
3.Water Supply WeII* r Geothermal(Heating/Cooling Supply) C Industrial/Commercial
r Irrigation C Municipal/Public/Community
r Residential Water Supply(single) C Residential Water Supply(shared)
r Wells>100,000 GPD
4. Date well was completed and ID#
Date Well Completed* Well ID# Well Yield
7/16/2021 Irrigation Well 30
(gallons per minute)"

5.Well Location
Facility/Owner Name* Facility ID#
Scott James Lake Phelps Lot
(Required) (If applicable)
County*
Washington
The selected county is within the Central Coastal Plain Capacity Use Area. Please reference your Capacity Use Water
Withdrawal Permit Number(CUxxxx)in Section 2.above.
Parcel Identification No. (PIN)
Physical Address* Street Address
4767 Shore Drive
Address Line 2
City State/Province/Region
Creswell NC
Postal/Zip Code Country
27928 USA
Latitude* 35.7601770000 Longitude*-76.5210307000
Decimal degrees Decimal degrees
6. Is(are)the well(s):* r Permanent r Temporary
7. Is this a repair to an existing well:* r Yes r No
If this is a repair,fill out known well construction information and a)plain the nature of the
repair under#21 remarks section or on the back of this form.
For multiple Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction,only 1 GW-1 is needed.
8a. Indicate TOTAL NUMBER of wells drilled: 1
9.Total well depth below land surface:(ft.) 9a.What is the depth of the casing from ground
80 surface?
For multiple wells Iistall depths if different 60
(example-3@200'and 2@100') in feet
10.Static water level below top of casing:(ft.) 11. Borehole diameter:
6.5 6.5
If water level is above casing,use"+" in inches
12.Well construction method:
r Auger r Air Rotary r Cable Tool
r Direct Push r Mud Rotary r Rotosonic
r Other
13. FOR WATER SUPPLY WELLS ONLY:
13a.Yield(gpm)
30 13a. Method of test:
If applicable Pumping

13b. Disinfection type:* 13b.Amount:*
HTH 3 ounces
14.WATER BEARING/FRACTURE ZONES
From To Description
in feet in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
From To Diameter Thickness Material
in feet in feet in inches
17.SCREEN
From To Diameter Thickness Material
60.00 80.00 2.00 Sch 40 PVC
in feet in feet in inches
18.GROUT
From To Material Emplacment Method &Amount
0.00 34.00 Hole Plug Poured
in feet in feet
19.SAND/GRAVEL PACK(if applicable)
From To Material Emplacment Method
34.00 80.00 Southern Products#3 Tremie
in feet in feet
20.DRILLING LOG
From To Description (color, hardness,soil/rock type,grain size,etc.)
0.00 24.00 Sand and Peat, interlayered
in feet in feet
24.00 80.00 Sand and Shells
in feet in feet
21.Remarks
Pump Set on 2 Joints of 1.25"Sure-Align PVC, 15SQ10-250, 3"Pump,240 Volt, Irony water
22.Site diagram or additional well details:
You mayupload additional well construction information here.
pdf only
CERTIFICATION INFORMATION
........................................................................................................................................................................................................................................................................................................................................................................................................................................................

*rJ By signing this form, I hereby certify that the well(s)was(were)constructed in accordance with 15A NCAC 02C
.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy of this record has been provided to
the well owner.
23.Certification* r� /
C%GCCfCCa�[ c rCc.'Y.4�L
Signature of Certified Well Contractor
Submittal Date 7/26/2021