GW1-2022-09511_Well Construction - GW1_20221017

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: 1
Hugo Rivas 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
3159
ft. fI: i
NC Well Contractor Certification Number
I5.OUTER CASING for multi-cased wells'OR LINER if a ticable)
McpherSon Well Drilling FROM TO °>AMEIER° TffiCIINESS MATERIAL
Company Name 0 ft. 195 ft. 12 ;;n. sch40 .pvc
16.INNER CASING OR TUBING eothermal closed loop)
2.Well Construction Permit#: FROM TO DIAMETERt ' THICKNESS MATFRrer.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft ft. :in.
3.Well Use(check well use): ft 2 in.
Water Supply Well: 17.SCREEN r
FROM TO DIAMETER 'SLOTSUX THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 195 fL 205 fL 2 in. 8 sch40 pvc
❑Geothermal(Heating/Cooling Supply) MResidential Water Supply(single) ft 195 ft 1D
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 tt 3 tt cement pour
❑Monitoring ❑Recovery 3 ft- 100 ft, bentonite tremmie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation '
19.SAND/GRAVEL PACK f applicalde -
[]Aquifer Storage and Recovery ❑Satinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
[]Aquifer Test ❑StormwaterDrainage 100 ft. 205 ft• gravel#1 1pour
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DFSCRIMON'(color,hardness,soilfrack type.gram size,etc.)
0 ft. 10 IL sand
4.Date Well(s)Completed: 10/5/22 well ID# 10 ff. 65 it. clay
5a.Well Location: 65 ft- 90 IL Sand
Patrick Richardson 90 It. 145 ft clay ``��'• ' m °'�-4•-
Facility/Owner Name Facility ID# fapplicable) 145 ft 160 fL sand I orf ' 7
113 Grape Mrytle In Whiteville NC 28472 160 ft 185 ft' clay
it ft. lfi,,s, w::cn r-r�.. _- �Uril
Physical Address,city,and zip 185 20U sand j ,,, ,, ,, _,
Columbus 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latnong is sufficient) 22.Certif! ' n:
N W k !� 10/5/2022
6.Is(are)the well(s): MPermanent or ❑Temporary Signs of Certified ell Con r Date
By signing thisform,l hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or LtNo I5A 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 captain the nature ofthe of this record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis 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:205 00 Submit this GW-1 within 30 days of wen completion per the following:
For malople wells list all depths ifdifferent(example-3@200'and 2@I00)
4 0 24a. For An Wells: Original fnmt�to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit, NC 27699-1617
lfwater level is above casing,use"+"
6 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.)
Program,1636 MSC,Raleigh,NC 276994636
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12.Well construction method; Rota ry 24c.For Water Sa 1 and Open-"op Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
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FOR WATER SUPPLY WELLS ONLY: A 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield Wm)20 Method of test:Air Permit Program,1611 MSC,Raleigh,-NC 27699-1611
Granulated 1/8 Ibs
13b.Disinfection e: Amount: