GW1-2021-00497_Well Construction - GW1_20211222

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Hugo Rivas . 1R 4
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
3159
ft. ft.
NC Well Contractor Certification Number
1�,�"11T>;It�i#Sl�4G foir_�ti�_u,t7-ca>zed"�clls t1k; ,k;1Fa" cable-' ,_
Mcpherson Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 230 ft- 2 in sch40 pvc
Company Name s s,
6 11V1NEX2. r.�I�1€`�II_T�I3Il�1G,` r7gat`�IoCd�oa
2.Well Construction Permit#: FROM I TO I DIAMETER f THICKNESS I MATERIAL
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 ❑Municipal/Public 230 ft 240 ft- 2 in' 8 sch40 pvc
❑Geothermal(Heating/Cooling Supply) IlResidential Water Supply(single) fit 230
❑industrial/Commercial ❑Residential Water Supply(shared) 11;.Gi201
❑h-ri ation ❑Wells>100,000 GPD FROM TO
MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fit. 3 it. cement pour
❑Monitoring ❑Recovery 3 ft. 100 ft- bentonite tremmie
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
--
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 100 fit' 240 fit• gravel#1 pour
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑TracerD U tti3 attladdiUanaiaheetsll nc
FROM TO DESCRIPTION(color,hardness,soil/rock e, rain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 80 fit. clay
/5/21 fit. fit. y
4.Date Well(s)Completed: Well ID# 80 90 sand
5a.Well Location: 90 f` 140 f` clay
Heidi Duncan 140 fit• 145 fit• sand
Facility/Owner Name Facility ID#(if applicable) 145 fit' 190 ff' clay
u�
78 Cardinal Ln Whiteville NC 28472 190 f` 210 ff• sand
Physical Address,City,and Zip 210 fL 225 fL clay
Columbus
County Parcel Identification No.(PIN) 225-240 sand
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certin a' n:
N W
6.Is(are)the well(s): ClPermanent or ❑Temporary Signaturl of Certifi Well Con ctor Date
By signing this form,I hereby certi ,that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A 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-I 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: 240 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list al/depths if dierent(example-3@200'and 2@100')
4 O 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
If 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(gpm) 2 Q 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