GW1-2022-01304_Well Construction - GW1_20220131

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NORTH CAROLINA
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WELL CONSTRUCTION RECORD (GW-1 )
EnvfronmertmfQua(Iry
Form GW-1 Well Construction Electronic Form
North Carolina Department of Environmental Quality
Division of Water Resources
November1
Submission ID#
G W 1-2022-01304
Are you submitting a scanned form?* Yes
No
CONTACT INFORMATION
.......................................................................................................................
Contact Name* Email Address*
Bill Magette [e-mail]
Is this a revision to the form you have previously submitted?*
Yes No
WELL CONSTRUCTION INFORMATION
........................................................................................................................................................................................................................................................................................................................................................................................................................................................
1.Who is installing these wells?*
Owner Well Contractor
1.Well Contractor Information:
Certiticate# Cert Level First Name Last Name Company Name
4265 A JUSTIN NIXON MAGETTE WELL&PUMP CO., INC.
2.Well Construction Permit#:
WS0701159
List all applicable well construction permits(i.e.Monitoring Wells,UIC,County,CCPCUA,etc.)
What type of well is this?* Injection Well Non-Water Supply Well
Water Supply Well (includes irrigation wells)
3.Water Supply Well* Geothermal (Heating/Cooling Supply) Industrial/Commercial
Irrigation Municipal/Public/Community
Residential Water Supply(single) Residential Water Supply(shared)
Wells> 100,000 GPD
4.Date well was completed and ID#
Date Well Completed* Well ID# Well Yield
1/20/2022 #3 150
(gallons per minute)"

5.Well Location
Facility/Owner Name* Facility ID#
John E Ferebee Farming, Inc Potato processing plant
(Required) (If applicable)
County* Parcel Identification No.(PIN)
Camden
Physical Address* Street Address
217 Lambs Rd
Address Line 2
city State/Province/Region
Camden NC
Postal/Zip Code Country
27921 us
Latitude* 36.3591020000 Longitude*76.1646100000
Decimal degrees Decimal degrees
................................................................................................................................................................................
6.Is(are)the well(s):* Permanent Temporary
7.Is this a repair to an existing well:* Yes No
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this form.
For multiple Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction,only 1 GW-1 is needed.
8a. Indicate TOTAL NUMBER of wells drilled: 1
9.Total well depth below land surface: (ft.) 9a.What is the depth of the casing from ground
130 surface?
For multiple wells list all depths if different 97
(example-3@200'and 2@100') in feet
10.Static water level below top of casing: (ft.) 11.Borehole diameter:
13 14
If water level is above casing,use"+" in inches
12.Well construction method:
Auger Air Rotary Cable Tool
Direct Push Mud Rotary Rotosonic
Other
13. FOR WATER SUPPLY WELLS ONLY:
13a.Yield(gpm)
150 13a.Method of test:
If applicable pump test
13b. Disinfection type:* 13b.Amount:
HTH 3 Ibs
14.WATER BEARING/FRACTURE ZONES

From To Description
97 107 sand
in feet in feet
120 130
in feet in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
From To Diameter Thickness Material
1.00 20.00 16.00 SDR 21
in feet in feet in inches
17.SCREEN
From To Diameter Thickness Material
97.00 107.00 6.90 SDR 21 PVC
in feet in feet in inches
120.00 130.00 6.90 SDR 21 PVC
in feet in feet in inches
18.GROUT
From To Material Emplacment Method&Amount
0.00 5.00 neat cement pour
in feet in feet
5.00 80.00 bentonite grout pump
in feet in feet
19. SAND/GRAVEL PACK(if applicable)
From To Material Emplacment Method
80.00 130.00 #3 SP tremie
in feet in feet
20. DRILLING LOG
From To Description(color, hardness,soil/rock type,grain size,etc.)
0.00 3.00 organic top soil
in feet in feet
3.00 52.00 sand
in feet in feet
52.00 92.00 silty sand&shells&clay
in feet in feet
92.00 110.00 Med.to fine sand&shells
in feet in feet
110.00 117.00 sand w/some clay
in feet in feet
117.00 130.00 med to fine sand&shells
in feet in feet

21. Remarks
Set 150S75-3 Grundfos pump w/7.5 hp 230 V 3 phase motor on 3"certalok
3"CSV and 202 well x trol
22.Site diagram or additional well details:
You may upload additional well construction information here.
pdf only
CERTIFICATION INFORMATION
* By signing this form, I hereby certify that the well(s)was(were)constructed in accordance with 15A NCAC 02C.0100 or
15A NCAC 02C.0200 Well Construction Standards and that a copy of this record has been provided to the well owner.
23.Certification
Signature of Certified Well Contractor