GW1-2022-09515_Well Construction - GW1_20221017

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Hugo Rivas 14.WATER ZONES
Well Contractor Name FROM TO DFSCRH'TION
3159 _ fL ft. F
NC Well Contractor Certification Number 15.OUTER CASING for mold cased wells OR LINER ifa ticable
Mcpherson Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name
0 ft 210 ft. 12 in sch40 Jpvc
16.INNER CASING OR TUBING cothermal closed-loop)
2.Well Construction Permit#• FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Cotmty,State.Variance,etc.) ft. ft '.'in.
3.Well Use(check well use): fL fL in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIM THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic 210 fL 220 fL 2 in. 8 sch40 pvc
❑Geothermal(Heating/Cooling Supply) MResidential Water Supply(single) ft. 210 ft- in'
❑Industrial/Commemial ❑Residential Water Supply(shared) 18.GROUT i
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 3 tt cement i, pour
❑Monitoring QRecovery 3 fL 100 0- bentonite tremmie
Injection Well: tL fL
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PAC K if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL' I EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 100 % 220 fL gravel#1 pour
❑Experimental Technology ❑Subsidence Control ft fL
❑Geothermal(Closed Loop) ❑Tracer 20,DRILLING LOG.attach additional sheets if necessary)
FROM I TO DESCRIMON:(color,hardness,soillrock type,grain sae,eto
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) I0 ft 60 fa Clay
4.Date Wells Com leted: 9/2/22 Well ID# 60 fr 75 ft sand - " to
5a.Well Location: 75 fL 140 fL clay
Marsdon Lews 140 ft• 180 sand j
Facility/Owner Name Facility ID#(ifapplicable) 180 fL 195 ft Clay
1598 Old Wilmington Rd Whiteville NC 28472 195 ft 220 ft sand 07
Physical Address,City,and Zip ft I ft
Columbus 21.REMARKS
County Parcel Identification No.(PIN)
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Ce ation:
N W M(KR _44� 9/2/2022
6.Is(are)the well(s): OPermanent or ❑Temporary Si tune ofC&tified Well dTntract5r i 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 ItNo 15A NCAC 02C.0100 or 15A NCAC 02C.6200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and erplain the nature ofthe afthis record has been provided to the well owner.
repair under#21 remarks section or on fire 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
dulled 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:220 (ff Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if&fferent(example-3@200 and 2@I00)
10.Static water level below top of casing:50 ( ) 24a. For Ali Wells: Original form to Division of Water Resources (DWR),
Ijwater level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter.6 (in.) 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
p } r Program,1636 MSC,Raleigh,NC 276919=1636
12.Well construction method: f o`a'7�' 24a 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 prodncint Duel 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm)20 Method of test• AI r M Permit Program,1611 SC,Raleigh,NC 27699-1611
A f
13b.Disinfection type:Granulated Amount;•1/8 Ibs