GW1-2022-09514_Well Construction - GW1_20221017

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Hugo Rivas 14.WATERTANES
Well Contractor Name FROM TO DESCRIPTION 1
3159 R. fr. I
II
NC Well Contractor Certification Number ft. ILI5.OUTER CASING(for multi cased wells OR LINER �f a Gcable
Mcpherson Well Drilling mom TO DIAMETER TmclavFss MATERIAL
Company Name 0 ft 215 ft. 2 1° Sch40 JPVC
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER I I THICKNESS I MATERIAL
List all applicable ivell construction permits(i.e.UIC,County,State.Variance.etc.) ft. ft. 1n.
3.Well Use(check well use): ft. it.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 215 ` 225 fL 2 1. 8 sch40 Pvc
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(Single) ft 215 fL in.
01ndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑lni ation ❑Wells>100,000 GPD FROM I TO MATFRr L EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fb 3 n cement pour
❑Monitoring ❑Recovery 3 ft. 100 ft. bentonite tremmie
Injection Well:
tt ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVELPACK if a livable
[]Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL. EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 100 f" 225 IL gravel#1 j' pour
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal QleatingfCooling Return) ❑Other(explain under#21 Remarks) FROM To DFSCREMON color,hardness,soiV-ck size,eta
0 ft 20 to sand
4.Date Well(s)Completed: 9/18/22 Well ID# 20 fk 75 IL clay
5a.Well Location: 75 f` 95 sand
Meredith Gore 95 n 140 ft. clay V ll
Facility/Owner Name Facility 1D#(ifapplicable) 140 H- 175 CL sand ty
220 Liza Ln Whiteville NC 28472 175 fL 200 ft. clay 2022
Physical Address,City,and zip 200 ft• 225 f`- sand -
r uni'l
Columbus 21•REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certilll tln:
N W 9/18/2022
6.Is(are)the well(s): MPermanent or ❑Temporary Signatufe ofCcrtificAVell Contmc Date
By signing this form,l hereby certify that the wM(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.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out brown well construction information and explain the nature ofthe ofthis record has been provided to the well oxner.
repair under#21 remarks section or on 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 ofwells (add'See Over'in Remarks Box).You may also attach additional pages ifnecessary.
h
drilled' 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 67 (fL) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdi,(jerent(example-3t200'and 2@100) i ;
50 24a. For All Wells: Original form to' Division of Water Resources (DWR),
10.Static water level below top of casing: OIL) Information Processing Unit,1617 MSC 1 Raleigh,NC 27699-1617
If water level is above casing,use"+" f
6 24b.For Injection Wells:Copy to DWR,J Underground Injection Control(IUC)
11.Borehole diameter. (in.) 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 roducin over 100.000 GPD:Copy to DWR,CCPCUA
Permit Program 1611 M C,Raleigh,NU 2 99-1611
13a.Yield(gpm) Method of test:Air.
13b.Disinfection type:Granulated Amount: 1/8 Ibs