GW1-2022-07025_Well Construction - GW1_20220726

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Hugo Rivas 'ti s
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
3159
ft. ft.
NC Well Contractor Certification Number
15CASIlVti for�mitU-casediWell., .QR'liINER: .a: iieable�>r
M cp h e rso n Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft 220 14 'n sch40 pvc
Company Name
lfi:1N1VER CASING.ARTUBIN6 'eothet'maCcl44 to
2.Well Construction Permit#: FROM TO DIAMETER 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. tt. in.
Water Supply Well: 1"CRF.EN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 220 ft. 240 ft. 4 in. 10 sch40 pvc
❑Geothermal(Heating/Cooling Supply) CJResidential Water Supply(single) ft• 220 ft. in.
❑Industrial/Cotrunercial ❑Residential Water Supply(shared) x18.,69()TIT
..., ,.
❑h-ri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 3 ft cement pour
❑Monitoring ❑Recovery 3 ft. 100 ft- bentonite tremmie
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
�9iSANDlGRAVEI:�PAl2K'ifa""tteti6le fs
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD `
❑Aquifer Test ❑StormwaterDrainage 100 ft' 240 ft gravel#1 pour
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer :r20-DRITEINGLAG'attach°addlddndl41&&Jfnecessa ) v
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiltrack type,grain size,etc.)
0 ft 20 ft sand-clay
4.Date Well(s)Completed: 5/16/22 Well ID# 20 ft. 80 ft' clay
5a.Well Location: 80 ft- 110 ft- sand
Linda Hinson 110 ft- 160 ft- clay
Facility/Owner Name Facility ID#(if applicable) 160 ft- 175 ft- sand
345 AD Hinson Rd Chadbourn NC 28431 175 ft- 200 ft- clay D
Physical Address,City,ty,and Zip 200 ft. 240 ft. sand J'
Columbus ,zl:HE1VfARKS aYP
rn Prt
County Parcel Identification No.(PIN) na
aix
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Cc tit- ation:
N w - 5/16/2022
6.Is(are)the well(s): InPermanent or ❑Temporary S mature of C rtified WcTfMntractor Date
By signing this fonn,I hereby certi6,that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction infonnation 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.
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: 240 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if dii Brent(example-3@200'and 2@100�
50 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ijwater 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(IUC)
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
13a.Yield m 80 Method of test AI r Permit Program,1611 MSC,Raleigh,NC 27699-1611
(gP )
13b.Disinfection type: Granulated Amount: 1/8 Ibs
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018