GW1-2022-07027_Well Construction - GW1_20220726

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Hugo Rivas
Well Contractor Name FROM TO DESCRIPTI j ON
ft. ft.
3159
NC Well Contractor Certification Number 7— eQIP C-ASING'f-eJn-ltPtiSe;d s O"IINNI R' s' lieable`r:-
M cp h e rso n Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft- 195 ft• 4 in. sch40
Company Name
It%INIVER'4�ASING OR T(3B11VG`"eo€lierriiaE cl-osed
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS 1 MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: t7: ItEEN .Via,,;` X,,: � .-. .. •,.. .. r
FROM I TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public 195 ft 215 ft- 4 in' 10 sch40 Jpvc
❑Geothermal(Heating/Cooling Supply) InResidential Water Supply(single) it- 195 ft- in.
❑Industrial/Commercial ❑Residential Water Supply(shared) exB.GRQUT .,..,.
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT L
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
i;t9:SANAIGRA'irJTt,I.
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 100 ft- 215 ft• Gravel#1 pour
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer €'ZO:ARtiti1NG;Lf1O ntfaeh addihonat"sLee&JItriecess
[]Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO I DESCRIPTION(color,hardness,solUrock a rain size,etc.)
0 ft. 20 ft. sand
4.Date Well(s)Completed. 5/24/22 Well ID# 20 ft• 110 ft• clay
5a.Well Location: 110 ft 135 ft sand
DSM Painting 135 fi• 180 ft• clay V
Facility/Owner Name Facility ID#(ifapplicable) 180 ft- 215 ft sand 6 2022
169 Water Lineway Riegelwood NC 28456 ft. ft.
rt. ft.
•W l
Physical Address,City,and Zip �/�
Columbus21•REnARxs-
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 4Cvation:
N "' 5/24/2022
6.Is(are)the well(s): nPermanent or ❑Temporary Signature WCertified Well Contractor Date
By signing thus 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 IlNo 15A NCAC 02C.0100 or I SA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well constructor information and explain the nature of the of this record has been provided to the well owner.
repair under 421 remarks section or on the back of this fort.
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-I 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: 215 (ft.)
For multiple wells list all depths ii(dierent(example-3@200'and 1@100� Submit this GW-1 within 30 days of well completion per the following:
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(gpm) Method of test:„
pi r Permit Program,1611 MSC,Raleigh,NC 27699-1611
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