GW1-2021-00493_Well Construction - GW1_20211222

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Hugo Rivas
Well Contractor Name FROM TO DESCRIPTION
ft, ft.
3159
ft. ft.
NC Well Contractor Certification Number
15~4!` ER.CiL�SI�_ dr,niuTtl-case s �1t:
Mcpherson Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft 170 ft 2 1 '" sch40 pvc
Company Name
14' SIN. slR T 1Ifi1 $flietYnettlu-- l .n
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL,,r
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft, ft. in.
3.Well Use(check well use): ft. tt. in.
Water Supply Well:
FROM I TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic 170 ft. 180 ft• 2 18 1sch40 pvc
❑Geothermal(Heating/Cooling Supply) IlResidential Water Supply(single) ft. 170 ft. I
❑Industrial/Commercial ❑Residential Water Supply(shared) � Rff
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 tt. 3 rt. cement pour
❑Monitoring ❑Recovery 3 ft. 100 ft. bentonite tremmie
Injection Well:
fL ft.
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERrar. EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 100 ft. 180 ft' gravel#1 pour
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer =2 p7ttl7asIG atEe tlottglh�lts3fies
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock typc rain size,etc.)
n n
0 ft. 30 rc.
4.Date Well(s)Completed: 12/2/2 Well ID# 30 ft. 100 tt.
6-
5a.Well Location: 100 ft• 130 ft' u l'" t•.
Rachel Brown 130 ft• 160 ft.
Facility/Owner Name Facility ID#(if applicable) 160 ft. 180 ft. 2
222 Brown George Dr Whiteville NC 28472 ft. ft. i ..
Physical Address,City,and Zip ft. ft.
Columbus r ' r
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:
N W /&/ l / 1 Z 17,1
6.Is(are)the well(s): [!]Permanent or ❑Temporary Sign tune ofCe fled Well rontr9tor Date
By signing this form,I hereby certifi,that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or IJNo I5A 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#21 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: 180 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 1@100')
40 24a. For All Wells: Original form to Division of Water Resources (DWR),
If Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
/f water level is above casing,use"+"
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: Copy to DWR,Underground injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rotary 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 producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gP m) 20 Method of test: Air Permit Program,1611 MSC,Raleigh',NC 27699-1611 13b.Disinfection type: granular Amount: 1/8
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018