GW1-2022-07024_Well Construction - GW1_20220726

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Hugo Rivas la4wTr�zizoNrs z- -
Well Contractor Name FROM TO DESCRIPTION
3159
rt. ft.
NC Well Contractor Certification Number
15 OUTEiI CA51NG or rtiulh-caseiEXells;UIt=LINER' 'a llcabie -
Mcpherson Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name
0 ft. 235 ft-• 2 in.
° sch40 pvc
_
1'6:1NNEIt'CASIIYGRTd_ISING<`eothrrmatctosedloo .`_
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits rz.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 31'17:SCItEE1V .x _ s `
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 235 ft 245 ft. 2 in' 8 sch40 pvc
❑Geothermal(Heating/Cooling Supply) [']Residential Water Supply(single) ft- 235 ft- in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18:GROUT, x t' 4�
❑hri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 f` 3 f` cement pour
❑Monitoring ❑Recovery 3 rt. 100 f` bentonite tremmie
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
1994ND/GI2A'VEL`_PACIC`ifa"itcawt` ,_.ter ., `�F� - . -t>..=,
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 100 f` 245 f` Gravel#1 JpvC
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 2q:I)R1ILINGSAG attach addihorial'sheets`itnecessa
FRODI TO DESCRIPTION(color,hardness,soil/rocke,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
0 f` 15 f` sand
4.Date Well(s)Completed: 6/9/22 Well ID# 15 f`' 120 f`' clay
5a.Well Location: 120 rt• 135 f` sand D
David Carter 135 f` 160 f` clay J11L
Facility/Owner Name Facility ID#(ifapplicable) 160 f` 180 f`• sand
2145 Whitehall Rd Whiteville NC 28472 180 f`• 225 f`• clay ;proc3osinguriil
Physical Address,City,and Zip 225 f`' 245 ft. sand
Columbus z1. ElrlARxs. N � s Y 3
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certif ation• l
N W e9 6/9/2022
6.Is(are)the well(s): InPermanent or ❑Temporary Signature of rtified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or I!No ISA NCAC 02C.0100 or 15A NCAC 01C.0100 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 for nz.
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 ofwells (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: 245 (ft.)
For multiple wells list all depths if dierent(example-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
60 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: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(TUC)
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
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gp-) 20 Method of test:Al r 13b.Disinfection type: Granulated Amount: 1/8 ll.,bs
Form GW-1 North Carolina Department Of Environmental Quality-Division of Water Resources Revised 6-6-2018