GW1-2022-07029_Well Construction - GW1_20220726

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Hugo Rivas _T4,ylr1`TER'2bi�iFS ? .
FROM TO DESCRIPTION
Well Contractor Name
3159 it. ft.
fit. fit.
NC Well Contractor Certification Number
15:'QI7TER"GAStNG for ptuih casedyroells;OR-LINER ;a `licalite
M cp h e rso n Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company
0 ft- 170 ft 2 in. 1sch40 pvc
P Y Name T6.INIVERCASIIYFi;DR'1'(71iIN(i CgthettTivat'closed too �.,r.>_ , �`a�.
2.Well Construction Permit#• FROM I 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): tt. fit. in.
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 170 ft- 180 ft- 2 in' 8 sch40 JPvc
❑Geothermal(Heating/Cooling Supply) InResidential Water Supply(single) ft- 170 ft- in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GRi]UT.,. x` }< r y4
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft 3 ft• cement pour
❑Monitoring ❑Recovery 3 ft- 100 ft- bentonite tremmie
Injection Well:
fit. f[.
❑Aquifer Recharge ❑Groundwater Remediation
x,19s SAND/GRA. L,PACK"ri'" lcalile
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 100 ft• 180 ft gravel#1 pour
❑Experimental Technology El Subsidence Control fit. fit.
El
Geothermal(Closed Loop) ❑Tracer `20.;DRILLR GX- attechiiddidonaltsrieetsif echssa ')
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remazks) FROM TO DESCRIPTION(color,hardness,soiltrock typc rain size,etc.)
ft• 35 ft• sand
4.Date Well(s)Completed: 5�22�22 Well ID# ft• 110 ft- clay
5a.Well Location: ft- 135 ft- sand
Jerome Rooks/Bryan Scott ft- 150 ft- clay
Facility/Owner Name Facility ID#(if applicable) fL 180 ft- sand J 2022
260 Angelas CT Whiteville NC 28472 ft. it. , i, Fl
Physical Address,City,and Zip ft. ft. (lt<otqMOG 9 UrIg
Columbus
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.C t ation•
N I'll
6.Is(are)the well(s): [!]Permanent or ❑Temporary Signature okertified Well Contractor Date
By signing thisform,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 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 information and explain the nature of the of(his record has been provided to the well owner.
repair under#21 remarks section or on the back of this fornn.
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 I 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: 180
For multiple wells list all depths if different(example-3@200'acid 2@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),
If water level is above casing,use"+"Stalk water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If
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)
20 Method of test: Al Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
r l.,
13b.Disinfection type: Granulated Amount: 1/8 lbs
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018