GW1-2021-00507_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
3159
ft, ft.
NC Well Contractor Certification Number
15;Ol}T'frRcsA,,S111� 3rain7dfiasedliv l3 ORETNER ff=;' b1e:'=, .
Mcpherson Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft- 205 ft- 2 In. sch40 pvc
Company Name
16" _ C SflvG QR-MIP1G ilie�rpatilosea isb r ;=
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): R. rt. in.
Water Supply Well: FROM TO DIAMETER w SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic 205 ft- 215 ft' 2 in. 8 SCh40 pvc
❑Geothermal(Heating/Cooling Supply) [nResidential Water Supply(single) ft• 205 ft• in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑hTi ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 3 ft. cement pour
❑Monitoring ❑Recovery 3 ft. 100 ft. bentonite tremmie
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
t.19 SAI+1TalG1#i 413 I'.1CK'if g `cttbl
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I To MATERIAL EMPLACEMEN^r METHOD
❑Aquifer Test ❑StormwaterDrainage 100 ft• 215 f` Gravel#1 pour
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer :2U: Ri71Gfit)G aEfsbtiddiUuttitlshNetsifnecfssd -,.._s
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock rain size,etc.
0 rt. 90 rt. clay
4.Date Well(s)Completed: 1 O/1 8/21 Well ID# 90 ft• 110 f` sand I,..
5a.Well Location: 110 f` 150 f` sand/clay
Jeffrey Russell 150 ft• 190 f` clay DEC 2
Facility/Owner Name Facility ID#(if applicable) 190 ft. 215 ft- sand
100 F M Stanley Rd Clarendon NC 28432
ft. rt.
Physical Address,City,and Zip tii
Columbus jz1.'IiA�ucs -> _, 1,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iatllong is sufficient) 22.Certifi ation:
N W
6.Is(are)the well(s): CJPermanent or ❑Temporary Sign e o K e fied Wel ont ctor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or nNo 15A NCAC 02C.0100 or I5A 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 ofthe of this record has been provided to the well owner.
repair under#21 remarkr 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 Ito 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: 21 5 (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')
L�O 24a. For All Wells: Original form to Division of Water Resources (DWR),
If Static water level below top of casing: 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: 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) 20 Method of test: „
pI r Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Granular Amount: 1/8
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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