GW1-2021-00505_Well Construction - GW1_20211222

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Hugo Rivas4.wTi�R _ ._
Well Contractor Name FROM ft. TO ft. DESCRIPTION
3159
NC Well Contractor Certification Number
15(QI)TER""G SING. ofaiiiiitl-cote .. s t7RIER >,°"`li$able��;
Mcpherson Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft, 218 ft. 4 in. sch40
Company Name
�Y4IN1�iI'<RG�` 11QR= .BAVG::`ettfh�rriiat>ECa'setlabo � � ..= '• ,`"
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: i7, ..?:=
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 218 ft' 238 ft' 4 in. 10 sch40 pvc
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft• 218 ft. I in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 6R"
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 3 ft. cement pour
❑Monitoring ❑Recovery 3 et. 100 ft. bentonite tremmie
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
�29:Sr1�l)1GReAY1 .PA
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aqui£erTest ❑StormwaterDrainage 100 ft• 238 ft' gravel#1 pour
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer =ZOR]1T111Y0 (4G attaetiadditlonal=sTtoetsitttec6ssr
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/mck type,gmin sim,etc.
0 ft. 10 ft. sand
4.Date Well(s)Completed: 11/2/21 Well ID# 10 ft• 140 ft clay 1,
5a.Well Location: 140 ft 155 ft sand
r
Wanda Sarini 155 ft. 156 ft. limestone
Facility/Owner Name Facility ID#(if applicable) 156 ft' 180 ft clay z 021
108 Brookes Ln Nakina NC 28455 180 ft. 190 ft. sand , .,..,,
Physical Address,City,and Zip 190 ft. 220 ft' clay
Columbus �. rAR>zs K_
County Parcel Identification No.(PIN) 220-238 sand
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: �J
N W Ald, atl)
6.Is(are)the well(s): OPermanent or ❑Temporary Sigma use ofC ed We Confractor Da e
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 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 hack 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 I 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: 238 (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 2@I00')
45 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(TUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rot+ary
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
(gP )
13a.Yield m 70 Method of test• p A I r 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