GW1-2022-01335_Well Construction - GW1_20220124

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Hugo Rivas 14.,3VTF1t`Z015 �U
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
3159
ft. ft.
NC Well Contractor Certification Number
15 ©Ck_ELR'C¢SI3_G or iiiuiH casedrell::O1t1NBR, :a` lrcatile
Mcpherson Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft- 150 ft. 2 ' in. sch40 pvc
Company Name
1K'.I1�t;F1t C�Si1YO.i4R`T:TIBINB.. eolhetTniaii3osed+loo .` -
2.Well Construction Permit#: FROM TO DIAMETER I 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:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 150 f` 1160 ft' 12 in. 8 SCh40 pvc
❑Geothermal(Heating/Cooling Supply) CJResidential Water Supply(single) it• 150 ft. in.
❑IndustrialICommercial ❑Residential Water Supply(shared) IB 613OIIT 4 Oh-ri ation ❑Wells>100,000 GPD FROM TO F MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 3 f` cement pour
❑Monitoring ❑Recovery 3 f` 100 ft- bentonite tremmie
Injection Well:
ft ft
❑Aquifer Recharge ❑Groundwater Remediation
�19�`.S1lNDlCsttAS'ilsLPAGK� i•aa c�til� . F f ,t -�-
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 100 f` 160 f` Gravel#1 pour
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer Q atfachkddltionsheetsitneclss
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock typc rain size,etc.
0 5 it. clay
4.Date Well(s)Completed: 1 2/24/21 Well ID# 5 f` 40 f` sand-shell
5a.Well Location: 40 f` 75 f` clay
John Morris 75 f` 95 f` sand
Facility/Owner Name Facility iD#(if applicable) 95 ft• 145 ft' clay
580 MT Morriath Church Rd Whiteville NC 28472 145 f` 160 f` sand
Physical Address,City,and Zip ft. ft.
Columbus
County Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latAong is sufficient) 22.Certi tion•
N `` 12/24/2021
6.Is are the wells : ClPermanent or ❑Tem ora Signa a of Certi d Wel tractor �— :�-Datc;, r .
( ) O p ry .... I -
by signing this form,I hereby certifi'that the we/l(s)was(were consirucied in accordance with
7.Is this a repair to an existing well: ❑Yes or ItNo 15A NCAC 02C.0100 or 15A NCAC 02C,0200 Well Construction yet t rd and that a copy
IJthis 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. JH ly
repair under#11 remarks 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 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: 160 (ft.)
For multiple wells list all depths ifdierent(example-3@200'and 2@1001 Submit this GW-1 within 30 days of well completion per the following:
45 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+"
f Static water level below top of casing: information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
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: Ro`a'1
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(gP m) 2 O Method of test• AI r Permit Program,1611 MSC,Raleigh,NC 27699-1611
p
13b.Disinfection type: Granular Amount: 1/y
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018