GW1-2021-00509_Well Construction - GW1_20211222

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Hugo Rivas =- ATxo
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
3159
ft. ft.
NC Well Contractor Certification Number
1S>QCITERG�ASING fori'iriaiH-2a¢edvella OR=L'INE12�ifa' eab7e � �. ;,=_.rr
Mcpherson Well Drilling FROM TO I DIAMETER THICKNESS MATERIAL
Company Name 0 ft- 245 ft- 2 in. sch40 pvc
X1+ISi1 R; SIPtGiDR [7BIlVi;. ebfhe>dugtffosed
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: T�� $N
FROM I TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 245 ft 255 It' 2 in.' 8 sch40 pvc
❑Geothermal(Beating/Cooling Supply) [!]Residential Water Supply(single) ft- 245 fL in.
❑industrial/Commercial ❑Residential Water Supply(shared) & R F,. ,
_ �
❑Im 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 It- bentonite tremmie
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
s7S:12AYBikC�C''ifa iciiltle c r
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 10
19.Se1
0 ft• 255 rt• gravel#1 pour
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20: ZtTL<ittYC (!fa atttfiddltiolial3hetsl[iecissa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock a rain sirs,etc.)F`
0 rt. 40 ft. sand r
4.Date Well 10/20/21 s)Completed: Well ID# 40 ft• 120 ff clay
5a.Well Location: 120 rt 155 fL sand DEC 22LilZf
Joshua Sellers 155 ft. 156 ft- limestone '
Facility/Owner Name Facility ID#(if applicable) 156 ff 160 ff sand
461 James Hinson Rd Clarendon NC 28432 160 ft• 220 ft- clay
Physical Address,City,and Zip 220 fL 255 ft- sand
Columbus z.> II-
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Cer'Ication:
N W 6 Z 4 Z I
6.Is(are)the well(s): [']Permanent or ❑Temporary Signature ofC rtifred MWCAtractor Date
By signing this form,I hereby certifft,that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 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 farm.
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: 255 (ft.)
For multiple wells list all depths ifdi/ferent(example-3@200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
10. 25 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwater level is above casing,use"+"Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
/f
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) Method of test: AIr
20 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