GW1-2021-02080_Well Construction - GW1_20210702

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Justin E. Nixon 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name RE-C 254 ft. 280 ft. Sand'
4265-A
O C 2021 295 ft. 330 1" Sand
NC Well Contractor Certification Number 1 u L ,e 15.OUTER CASING for multi-cased wells OR LINER if a livable
Magette Well&Pump Co., Inc. J 1'�1� FROM TO DIAMETER THICKNESS MATERIAL
y rsQrgcslnQ lJ +2 ft. 48 ft 10 In. SCh 40 PVC
Company Name Inforr`,a i�r
pw R Sedon 16.INNER CASING OR TUBING 'eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) +3 ft. 260 ft- 4.5 in' SDR 17 PVC
3.Well Use(check well use): 280 ft- 295 ft. 4 in. SDR 17 PVC
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []MunicipaVPublic 260 f- 280 1" 4 In- 0.032 sch 40 pvc
Geothermal(Heating/Cooling Supply) []Residential Water Supply(single) 295 ft- 330 ft. 4 i"' 0.032 SCh 40 pVC
Industrial/Commercial []Residential Water Supply(shared) IS.GROUT
Irrigation FROM I TO MATERIAL EMPLACEMENT M1IEI'HOD&AMOUNT
Non-Water Supply Well: 3 H• 236 fL Quik-Grout Pumped thru Tremie
ix Monitoring []Recovery 0 ft. 3 ft. Quikrete Pour
Injection Well:
_ ft. fL
i Aquifcr Recharge []Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
( Aquifer Storage and Recovery []Salinity Barrier FROM I TO I MATERIAL EMPLACEMENT METHOD
(-Aquifer Test []StormwaterDrainage 236 ft- 340 ft. S.P.#2 Tremie
Experimental Technology []Subsidence Control ft. H.
Geothermal(Closed Loop) []Tracer 20.DRILLING LOG attach additional sheets If necessa
Geothermal(Heating/Cooling Retu F1 Other(explain under#21 Remarks) I
FROM TO DESCRIPTION color,hardness,soil/rack type,grain size,eta
0 fL 72 ft- Clayey Sand
4.Date Well(s)Completed:10-26-20 Well 1D#TW-361ackCreek 72 fL 88 It- Clay
5a.Well Location: 88 ft' 96 "' Sand with Sandstone
Town of Lake Waccamaw 96 IL 124 ft. Clay and Shells
Facility/Owner Name Facility lD#(ifapplicable) 124 It. 158 ft. Sand, Sandstone, minor Clay
205 Fleming Dr., Lake Waccamaw, NC 28450 158 ft. 190 H• Clay
Physical Address,City,and Zip ft. ft- Continued on back
Columbus 21.REMARKS
County Parcel Identification No.(PIN) Tail Pipe 330-335-4-inch, SDR 17, PVC
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22.Certi atio
34.293306 78.557503
N w 10-30-20
6.Is(are)the wells)!X Permanent or []Temporary Sign re of Certified Well Contractor Date
signing this form,I herebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or .X No with 15A NCAC 01C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature ofthe copy of this record has been provided to the well owner.
repair under#21 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 site details or well
construction,only l GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:1 SUBMITTAL INSTRUCTIONS'
9.Total well depth below land surface: 335 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: 9'60 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:8.75 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
Mud Rotary above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 55 Method of test:Pump 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit;one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: 1 lb completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

20.DRILLING LOG(CONTINUED)
FROM TO DESCRIPTION
190 ft 204 ft Sand
204 ft 254 ft Mostly Clay,some sand
254 ft 280 ft Sand
280 ft 295 ft Clay and sand
295 ft 330 ft Sand
330 ft 344 ft Clay
344 ft 354 ft Mostly Sand,Clay content increasing downward
354 ft 368 ft Clay
368 ft 390 ft Mostly Sand some clay
390 ft 424 ft Clay