GW1-2022-08930_Well Construction - GW1_20220925

w
®,
NORTH CAROLINA
ilk
WELL CONSTRUCTION RECORD (GW-1 )
EnvfronmertmfQua(Iry
Form GW-1 Well Construction Electronic Form
North Carolina Department of Environmental Quality
Division of Water Resources
November1
Submission ID#
G W 1-2022-08930
Are you submitting a scanned form?* Yes
No
CONTACT INFORMATION
.......................................................................................................................
Contact Name* Email Address*
John Shelley [e-mail]
Is this a revision to the form you have previously submitted?*
Yes No
WELL CONSTRUCTION INFORMATION
........................................................................................................................................................................................................................................................................................................................................................................................................................................................
1.Who is installing these wells?*
Owner Well Contractor
1.Well Contractor Information:
Certiticate# Cert Level First Name Last Name Company Name
2097 A JOHN SHELLEY SHELLEY PUMP&WELL SERVICE
2.Well Construction Permit#:
2022-00327
List all applicable well construction permits(i.e.Monitoring Wells,UIC-Underground Injection Control,CCPCUA-Central Coastal Plain Capacity Use Area,County,
etc.)
What type of well is this?* Injection Well Non-Water Supply Well
Water Supply Well(includes irrigation wells)
3.Water Supply Well* Geothermal (Heating/Cooling Supply) Industrial/Commercial
Irrigation Municipal/Public/Community
Residential Water Supply(single) Residential Water Supply(shared)
Wells> 100,000 GPD
4.Date well was completed and ID#
Date Well Completed* Well ID# Well Yield

9/5/2022 25
(gallons per minute)"
5.Well Location
Facility/Owner Name*
Elvira White-Lewis Facility ID#
(Required) (If applicable)
County* Parcel Identification No.(PIN)
Cumberland
Physical Address* Street Address
5142 Boxcutt Lane
Address Line 2
City State/Province/Region
Hope Mills North Carolina
Postal/Zip Code Country
28348 Cumberland
Latitude* 35.0181300000 Longitude*-78.9670800000
Decimal degrees Decimal degrees
........ ................ ......... ........................... ........................... ......... ......... ......... ...................
6.Is(are)the well(s):* Permanent Temporary
7.Is this a repair to an existing well:* Yes • No
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this form.
For multiple Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction,only 1 GW-1 is needed.
8a.Indicate TOTAL NUMBER of wells drilled: 1
9.Total well depth below land surface: (ft.) 9a.What is the depth of the casing from ground
82 surface?
For multiple wells list all depths if different 71
(example-3@200'and 2@100') in feet
10.Static water level below top of casing: (ft.) 11.Borehole diameter:
41 8
If water level is above casing,use"+" in inches
12.Well construction method:
Auger Air Rotary Cable Tool
Direct Push Mud Rotary Rotosonic
Other
13. FOR WATER SUPPLY WELLS ONLY:
13a.Yield(gpm)
25 13a.Method of test:
If applicable air
13b. Disinfection type:* 13b.Amount:
Hth 2 cups

14.WATER BEARING/FRACTURE ZONES
From To Description
53 60 tan sand w streaks clay
in feet in feet
70 80 grey coarse sand w wood
in feet in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
From To Diameter Thickness Material
0.00 71.00 4.00 sch40 pvc
in feet in feet in inches
80.00 82.00 4.00 sch40 pvc
in feet in feet in inches
17.SCREEN
.................................................................................
From To Diameter Thickness Material
71.00 in feet 80.00 sch40 pvc
in feet in inches
18.GROUT
From To Material Emplacment Method&Amount
0.00 20.00 hole plug pour
in feet in feet
19. SAND/GRAVEL PACK(if applicable)
From To Material Emplacment Method
65.00 80.00 pea garvel pour
in feet in feet
20. DRILLING LOG
From To Description(color, hardness,soil/rock type,grain size,etc.)
0.00 23.00 orange clay
in feet in feet
23.00 50.00 streaks clay&sand
in feet in feet
50.00 65.00 tan sand
in feet in feet
65.00 70.00 clay
in feet in feet
70.00 80.00 grey coarse sand w wood
in feet in feet
21. Remarks

22.Site diagram or additional well details:
You may upload additional well construction information here.
pdf only
CERTIFICATION INFORMATION
.......................................................................................................... ..............................
* By signing this form, I hereby certify that the well(s)was(were)constructed in accordance with 15A NCAC 02C.0100 or
15A NCAC 02C.0200 Well Construction Standards and that a copy of this record has been provided to the well owner.
23.Certification
7
Signature of Certified Well Contractor