GW1-2021-02409_Well Construction - GW1_20210601

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
15
1.Well Contractor Information: q
Justin E. Nixon RECEb\1�� 14.WATER ZONES
FROM I TO DESCRIPTION
Well Contractor Name
4265-A JON X L 194 ft 222 ft- Medium-to Fine-Sand
9 Unit 222 ft- 244 ft• Medium-to Fine-Sand
NC Well Contractor Certification Number n P fQf,essln 15.OUTER CASING for multi-cased wells OR LINER if a livable
nfarr'ratlo QrI FROM TO DIAMETER THICKNESS MATERIAL
Magette Well &Pump Co., Inch. DWR sect
on
ft. 47 ft. 10 Sch 40 PVC
Company Name 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) +2 ft. 194 ft- 4.5 i" SDR-17 PVC
3.Well Use(check well use): 216 ft. 222 ff• 4 in- SDR-17 PVC
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public 194 IL 216 ft• 4 in. 0.020" SCh 40 PVC
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) 222 ft• 244 ft• 4 in.! 0.020• SCh 40 PVC
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
J Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 5 ft. 184 ft- Quik-Grout Pump thru Tremie
R Monitoring Recovery 0 ft. 5 fr. Quiekrete Pour
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
_,Aquifer Test OStormwater Drainage 184 ft. 250 ft- SP#2` Tremie
:]'Experimental Technology Subsidence Control ft. ft.
RGeothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soittrock type,grain size etc.
0 ft. 23 ft- Sand
4.Date Well(s)Completed:3-8-21 Well ID# � Peedee 23 ft. 32 ft. Clay
5a.Well Location: 32 fL 80 ft• Coarse sandgrading to finer sand
Lake Waccamaw 80 ft- 110 ft- Mostly Clay
Facility/Owner Name Facility ID#(if applicable) 110 ft. 130 ft- Mostly Sand, sandstone w/some clay
205 Fleming Dr., Lake Waccamaw, NC 28450 130 ft- 166 & Clay with minor sand
Physical Address,City,and Zip ft. ft- Continued on back
Columbus 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Cc iflcation:
34.281039 N 78.464944 W
3-12-21
6.Is(are)the well(s)oPermanent or Temporary 71,
ture of Certified Well Contractor Date
ning this form,I hereby certify that the ivell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or )No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the 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 I GW-I 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: 244 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths it-different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing:16.31 (ft.) Division of Water Resources,Information Procgssing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8.75 (in.) 24b. For Infection 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) 60 Method of test: Pump 24c. For Water Supply& Infection 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: 8 oZ completion of well construction td 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 uTO y DESCRIPTION
166 ft 186 ft Sand and minor clays
186 ft 194 ft Clay
194 ft 216 ft Medium-to Fine-Sand
216 ft 222 ft 1 Clay and sand
222 ft 244 ft Medium-to Fine-Sand
244 ft 350 ft I Clay