GW1-2022-07033_Well Construction - GW1_20220726

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: j
Hugo Rivas C4 y1A1ERZONFS z ,
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
3159
NC Well Contractor Certification Number ;S:OI7TER CASING for multi casedaells,ORLIIR t[a cable-'r r
Mcpherson Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 215 ft. 4 in. sch40 pvc
INNER EASING OWTIIBING 'euihei mat closed-Ida` '=
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS 7 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:
FROM I TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 225 fL 235 ft- 4 in. 10 sch40 pvc
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft- 1225 ft- in.
❑hidustrial/Commercial ❑Residential Water Supply(shared)
❑Irri 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 ;9:•SANDLGRAVEi PACK"if,a` lieatile❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD \
❑Aquifer Test ❑Stormwater Drainage 100 ft- 235 ft. Gravel#1 pour
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer Zp DRIIINGOG"atticeh''addihonalsheetsifnecessa .. ._
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type, rain size,etc.)
G 0 ft. 60 rt. clay
4.Date Well(s)Completed: 6/22/22 Well ID# 60 ft- 95 ft. sand
5a.Well Location: 95 fi. 135 ft. clay
Kenneth B. Long 135 ff• 145 ft- sand
Facility/Owner Name Facility ID#(if applicable) 145 ft' 1180 ft. clay ift 2 J
2022
3702 Sidney Cherry Grove Rd Clarendon NC 28463 180 ft- 195 1 sand irwocmu4an Proi:a*"V Una
Physical Address,City,and Zip 195 ft- 200 ft- sand-clay DWOMOG
Columbusi• M^>:lcs.
County Parcel Identification No.(PIN) 200-235 sand
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Cc ation•
N W l— 6/22/2022
6.Is(are)the well(s): CJPermanent or ❑Temporary Signature of t2itified Well Contractor Date
By signing this fonn,l hereby certify 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.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 fonn. 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) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@100�
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 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) 50 Method of test:AI r Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Granulated Amount: 1/8 lbs
Forth GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018