GW1-2022-09513_Well Construction - GW1_20221017

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Hugo Rivas 14.WATER ZONES [ i
Well Contractor Name FROM TO DFSCRUMONI
3159 ft. ft.
11. IL �
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable
Mcpherson Well Drilling FROM To DiAnrF^rcR TffiCIINFSS MATERIAL
0 ft 190 ft 2 JSCh40 1pvc
Company Name 16.INNER CASING OR TUBING(geothermal closed400
2.Well Construction Permit#: FROM TO DIAMETER. -THICKNESS I MATERIAL
List all applicable well construction permits f.e.UIC,County,State,Variance,etc.) ft. fL in.
3.Well Use(check well use): ft. R. in
Water Supply Well: 17.SCREEN
FROM TO DIAMETER •SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 190 sr. 200 ft 2 in' 8 sch40 pvc
❑Geothemlal(Heating/Cooling Supply) MResidential Water Supply(single) fL 190 ft in.
❑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 ft 3 cement 1, pour
OMonitoring ❑Recovery 3 ft 100 R- bentonit6 tremmie
Injection Well:
fL ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if atiolicable
❑Aquifer Storage and Recovery El Salinity Barrier FROM TO MATERIAI. EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 100 ft 200 ft• gravel#1 pour
❑Experimental Technology ❑Subsidence Control ft. it. ;
[]Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets ifnecessa
FROM TO DFSCR MON color,hardness,wilfroek type,grain size,etc.)
❑Geothermal eating/Cooling Return) ❑Other(explain under#21 Remarks)
0 n• 45 ft- clay-sand
4.Date Well(s)Completed: 10/6/22 well lw 45 ft 90 ft clay
5a.Well Location: 90 tt• 110 ft sand s
Tammy Reaves Lee 110 ft 150 Rt clay i, `e. ` � .. '• $``
Facility/Owner Name Facility 1D#(if applicable) 150 "' 165 ft sand I.
4470 Seven Creeks Hwy Nakina NC 28451 165 ft 175 ft clay
Physical Address,City,and Zip 175 ft 200 fL sand 'M 'n 1pp
�Rll
Columbus 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certificati l
N W � ,e 10/6/2022
6.Is(are)the well(s): InPermanent or ❑Temporary Signature of Eyertified Well&ntractor 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 lo1No ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fdl out known well construction information and explain the nature of the ofthis record has been provided to the well,owner.
repair under#21 remarks section or an 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
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9.Total well depth below land surface:200 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-C3 a200'and 2@100)
10.Static water level below top of using:45 (f<-) 24a. For All Wells: Original form to Division of Water Resources (DWR),
I10.Staticter is above casing,use op Information Processing Unit, 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 24e.For Water Supply and Open-"op Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) comity environmental health department,of the county where installed
FOR WATER SUPPLY WELLS ONLY:
p 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13s.Yield(gpm)20 Method of test A I r Permit Program,1611 MSC,Raleigh;NC 27699-1611
13b.Disinfection type:Granulated Amount: 1/8 Ibs
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