GW1-2022-01331_Well Construction - GW1_20220124

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
I
Hugo Rivas ; : _ > <<_FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
3159
NC Well Contractor Certification Number 15.,4iY1TE1t=Q S1TiG fm tiiulti eaed'ivs9)s QR 3yINBlt lleable
Mcpherson Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 222 ft. 2 to sc4O pvc
Company Name
�16�1N1VER' IN-OR�'1�7B1I!TG."�eltheeuial`clugetl-ioa ,-
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) f[. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 7; GRE1
FROM I TO DIAMETER z. SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 222 r" 232 ft- 2 In• 8 sc40 pvc
❑Geothermal(Heating/Cooling Supply) [!]Residential Water Supply(single) ft 222 ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.;GR1113T 3 ,J.. a g
❑hTi ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNTx
Non-Water Supply Well: 0 f`' 3 r` cement pour
❑Monitoring ❑Recovery 3 ft- 100 ft- bentonite tremmie
Injection Well:
n. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19 /QLACK' a lchtil¢
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 100 r` 232 f` gravel#1 pour
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer Zi� IlT1L11VG =fG attsdbaddtUonalislreetsffineoessr «.:a
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiltrock e,gnin size,ere.)
C n
0 rt. 25 rt. clay
4.Date Well(s)Completed: 12/15/21 Well ID# 25 r` 35 f` sand
5a.Well Location: 35 r`' 90 r` clay
Arthur Thompson 90 f` 91 f` limestone
Facility/Owner Name Facility ID#(ifapplicable) 91 r` 110 f`' sand
1359 Gores Trailer Rd Whiteville NC 28472 110 r` 175 f` clay
Physical Address,City,and Zip 175 f`' 190 f`' sand
Columbus z1.xE�►tARllcs r= _ ri _
County Parcel Identification No.(PIN) 1 90-21 0 clay 21 0-232 sand
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
6.Is(are)the well(s): nPermanent or ❑Temporary Signature o/Ccrtified'Welf Contractor Date
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 01C.0/00 or 15A NCAC 01C.0100 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 owvrer.
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well de
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to prude 9ddi'tional'well'construction info
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may alto attach additional'pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS AN 2 4 ?R��
9.Total well depth below land surface: 232 (ft.)
For multiple wells list all depths ifdi/ferenr(example-3 200'and 1@100') Submit this GW-1 within 30 days'pf well completion per the following:
50 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwater level is above casing,use"+"
f Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 i I
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
I
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) 30 Method of test: Air
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Granular Amount: 1/p
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018