GW1-2022-01332_Well Construction - GW1_20220124

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Hugo Rivas
Well Contractor Name FROM TO DESCRIPTION
rt. rt.
3159
rt. ft.
NC Well Contractor Certification Number
t5:(3tl_TEItG9SIi�`ts rtri''uiulta-easedwells:OR�II�FEk'if-- licsbte� � ,.s`
Mpherson Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 210 ft- 4 in. sch40 pvc
Company Name <Y6,1N�(E1t�ASINt;pR;2_I)13TNG. $fEltet'dSafiFl"dsed lao :: - _
2.Well Construction Permit#' FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State, Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well:
FROM I TO DIAMETER SLOT SIZE THICKNESS t.MATERIAL
❑Agricultural ❑Municipal/Public 210 rl' 230 ft- 4 in. 10 Isch40 pvc
❑Geothermal(Heating/Cooling Supply) L Residential Water Supply(single) ft 210 ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 8:&ROOT e4 :y
❑Irri ation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 rt. 3 ft. cement pour
❑Monitoring ❑Recovery 3 ft. 100 rt• bentonite tremmie
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.'SANDLGRAYEUP CK ira"tti1e +,. ;,
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO MATERIAL I EMPLACEMENTMETHOD
❑Aquifer Test ❑StormwaterDrainage 100 rt' 230 "L Gravel#1 pour
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer Iton3il.islteeis}Cneetssa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/mck type,gritin size,etc.) _5
0 ft. 40 rt• sand-clay
4.Date Well(s)Completed: 1 1/25/21 Well ID# 40 ft- 55 ft. sand
5a.Well Location: 55 rt 120 ft. clay
Troy Brooks 120 rt• 121 «• limestone
Facility/Owner Name Facility ID#(if applicable) 121 rt' 180 rt' clay
23555 Hwy E (74-76) Bolton NC 28423 180 rt• 181 rt• limestone
Physical Address,City,and Zip 181 rt' 210 rt• clay
Columbus1.R1w1ARxs=
County Parcel Identification No.(PIN)
210-230 sand
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Cer' ation:
N W �X/ 11/25/2021
6.Is(are)the well(s): nPermanent or ❑Temporary Signattlre of rertifed Well ctor 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.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 ofthe of this record has been provided to the well owner,._
`` ? ',ram•'^ ;:y
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:p•,-
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provided tional well construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may als di oMp�es if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 230 (ft.) (ter t, .
For multiple wells list all depths ifdt'/ferenr(example-3@200'and 2@100') Submit this GW-1 within 30 days of well completion per the folloMying:
50 24a. For All Wells: Original form to Division of Water Resources (DWR),
If
f water Level is above casing,use"+"Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
6 24b.For Injection Wells: Copy to DWR,Underground Injection Control JUC)
11.Borehole diameter: (in.) 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)40 Method of test: AI r
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Granular
Granular Amount: 1/8
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018