GW1-2022-09512_Well Construction - GW1_20221017

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Hugo Rivas 14.WATER.ZONES' }>
Well Contractor Name
FROM TO I DESCRIPTION 1
3159 ft. ft.
NC Well Contractor Certification Number 15.OUTER.CASING for multi-cased we OR LINER.if a livable
Mcpherson Well Drilling r•RoM TO DIAMETER1 THICIINESS MATERIAL
0 ft. 157 s 2 sch40 pvc
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM To I DIAMETER i I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. n iin.
3:Well Use(check well use): ft. fL 'in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER :SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public it �fl .
in.
157 1672 8 ' sch40 pvc
[]Geothermal(Heating/Cooling Supply) InResidential Water Supply(single) ft 157 im
pindustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑hri ation ❑Welts>100,000 GPD FROM TO MATERIAL' EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 3 ft. cement j: pour
❑Monitoring ❑Recovery 3 ft. 100 ft. bentonite tremmie
Injection Well:'
iG tt. I
❑Aquifer Recharge []Groundwater Remediation
19.SAND/GRAVEL PACK f applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL; EMPLACEMENTMETHOD
❑Aquifer Test ❑StorrawaterDrainage 100 ft. 167 ft- gravel#1 pour ;
❑Experimental Technology ❑Subsidence Control ft. fL
❑Geothermal(Closed Loop) []Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color.badness,soil/rack type,grain Stu,etc.)
10/12/22 0 6- 10 ft. sand-clay
4.Date Well(s)Completed: Well 101# 10 ft 100 m clay
5a.Well Location: 100 m 110 fL sand '
Dinah Reaves Elkin 110 ` 130 Ht clay V
- r
Facility/Owner Name Facility lD#(if applicable) 130 ft- 145 tt. clay
1184 Jimmie Hester Rd Clarkton NC 28433 145 ` 167 fL sand OCT 17.2022
Physical Address,City,and Zip ft. ft.
Columbus 21.REN ARKS
County Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one laUlong is sufficient) 22.Ce C lion:
N `�' 10/12/2022
6.Is(are)the well(s): C1Permanent or ❑Temporary Signat&e of Certifleftell 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 MNo 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 explain the nature ofthe of this record has been provided to the well owner.
repair under#21 remarks section or on the back of thisform. 1'
23.Site diagram or additional well details:
8.For Geoptohe/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.SUBMITfAL INSTRUCTIONS
9.Total well depth below land surface: 167 (ft)
For multiple wells list all depths l(dierent(example-3@200'and 2@1001 Submit this GW-1 within 30 days of well completion per the following:
1 '
10.Static water level below top of casing:40 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use„+"If Processing Unit,1617 MSC,Raleigh,NC 27699-1617
6 24b.For Injection Wells:C DWR,
Il.Borehole diameter:. .. (in.) Copy to Underground Injection Control(IUC)
o Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rotary 24c.For Water Sup Iy and Open-Lo�p Geothermal Return Wells:Copy to the
(i.e.auger,ratarA cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producineover 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigb,NC 2
p 7699-1611
13a.Yield Writ)20 Method of test:~i r 1,
13b.Disinfection type:Granulated Amount: 1/8 lbs