GW1-2022-07030_Well Construction - GW1_20220726

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Hugo Rivas 14.:war>Iiz�iv>s ,,..
WellContractor Name
FROM TO
3159 ft. ft. DESCRIPTION
ft. ft.
NC Well Contractor Certification Number ?i5 p1}gER CASIIiIG fdr'nultl-caspdtiYeUs URUINEIt(tf'ar bcable:'
Mcpherson Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft- 215 ft- 4 in. sch40 1pvc
Company Name
;,L6;'INnRt315INGOR;TUBffiG- euflieicmalctosedloo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS � MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. ft.
3.Well Use(check well use): ft. ft.
Water Supply Well: 7 EEN:S6
1
FROM I TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public 215 ft 235 ft- 4 "' 10 sch40 pvc
❑Geothermal(Heating/Cooling Supply) InResidential Water Supply(single) ft- 215 ft• I in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑hri ation ❑Wells>100,000 GPD FROM I TO MATERLII, 4 EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 it. 3 ft. cement pour
❑Monitoring ❑Recovery 3 It. 100 ft bentonite tremmie
Injection Well:
ft, ft.
❑Aquifer Recharge ❑Groundwater Remediation s I9i"SAN1)1GRAVEi;PACf{'if "lieatle , -�
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 100 ft• 235 ft- gravel#1 pour
❑Ex erimental Technology ❑Subsidence Control
ft. ft.
P gY
❑Geothermal(Closed Loop) ❑Tracer 2Q'I)RTt.LINGIYjC, attactiudthtlurialalteetsi[necessa - ,
❑Geothermal(Heating/Cooling Return)
TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.
) ❑Other(explain under#21 Remarks) 0 ft. 50 ft. clay
4.Date Well(s)Completed: 5/1 8/22 Well ID# 50 ft. 75 ft. sand
5a.Well Location: 75 ft- 140 ft- clay
Eddie Faircloft 140 ft- 160 ft- sand
Facility/Owner Name Facility ID#(if applicable) 160 ft- 195 ft- clay JUL 2
Pleasant Plains Church Rd Whiteville NC 28472 195 ft- 235 ft• sand
Physical Address,City,and Zip ft. ft. � 8 V
Columbus 21:12EMARKS, r' k, _ _
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IaUlong is sufficient) 22.Certi cation•
N `'`' 5/18/2022
6.Is(are)the well(s): InPermanent or ❑Temporary Signature o crtificd ell 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 IlNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fell out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#11 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: 235 (ft.)
For multiple wells list all depths if different(example-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the followimg:
60 24a. For All Wells: Original form to Division of Water Resources (DWR),
If
f water level is above casing,use"+"Static water level below top 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) 8 O Method of test:AI r
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Granulated Amount: 118 Ibs
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018