GW1-2022-01336_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
ft. ft.
3159
ft. ft.
NC(Well Contractor Certification Number 1 C4t31BR cA�Il�fi atilfTti caiSi't�Vl11S I)�3�Ii1TER Hs
Mcpherson Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 rt• 210 rt 2 '" sch40 pvc
Company Name _
�. DR_Tf3wy. '#tliersua"`t`elosett�no
2.Well Construction Permit#• FROM TO DIAMETER THICKNESS MATERIAL s
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) rt• [t. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 210 1220 ft 2 1n• 8 sch40 pvc
❑Geothermal(Heating/Cooling Supply) IlResidential Water Supply(single) ft 210 fL in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑hTi ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 3 ft. cement pour
[]Monitoring ❑Recovery 3 rt. 100 [t. bentonite tremmie
Injection Well:
[]Aquifer Recharge ❑Groundwater Remediation Y
1.:P
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 100 rt' 220 r` Gravel#1 pour
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer rill- ftT1CF ,atEa�ihildit(oFialalie� 3[nec
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiVrock type,grain size,etc.)
0 ft. 5 ft. clay
4.Date Well(s)Completed: 1 2/28/21 Well ID# 5 rt 45 rt sand-shell
5a.Well Location: 45 [`' 90 r`' clay
Quran Lennon 90 rt 120 rt• sand
Facility/Owner Name Facility ID#(if applicable) 120 rf 165 rf clay
399 McCullum Rd Clarkton NC 28433 165 rt• 175 rt sand
Physical Address,City,and Zip 175 rt• 200 rf clay
Columbus
County Parcel Identification No.(PIN) 200-220 sand
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Cc tifica n:
N W 12/28/2021
6.Is(are)the well(s): nPermanent or ❑Temporary Signatuff of Certifiq^c11 Con or Date
By signing this form,I hereby certii i,that the we/l(s)was(w re)con$trucled in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 15A NCAC 01C.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 form.
JAN 2 4 20c_
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: 220 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3@200'and 1@100')
40 24a. For All Wells: Original form to Division of Water Resources (DWR),
If Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
/f water level is above casing,use"+"
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: Rotar 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-) 20 Method of test: I r
Pem it Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Granular Amount: 1/8
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018