GW1-2022-09516_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
FROM TO DESCRIPTION;
Well Contractor Name
fL ft.
3159 tt lc
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NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if Gcable
Mc herson Well Drilling FROM TO DIAMETER THCKNESS MATERIAL
p g 0 ft 205 ft. 4 in, sch40 PVC
ContpanyName 16.INNER CASING OR TUBING(eothermal closed-loop)
2.Well Construction Permit#: FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) ft. fL in.
3.Well Use(check well use): ft R, to
Water Supply Well: 17.SCREEN
FROM TO DIAMETER -SLOTS12E THICKNESS MATERIAL.
❑Agricultural ❑Municipal/Public 205 fL 225 ft 4 I' 10 sch40 pvc
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) fL 205 fL 'a-
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
111ni ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 3 "• cement:' pour
❑Monitoring ❑Recovery 3 n• 100 ft- bentonite tremmie
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
-19.SAND/GRAVEL PACKrarappucabiel
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StonnwaterDrainage 100 It- 225 ff gravel#1 pour
❑Experimental Technology OSubsidence Control It. ft.
❑Geothermal(Closed Loop) []Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heatin Cooling Retum) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,-it/rock type sru:,etc.
10/1/22 o rt. 50 ft clay
4.Date Well(s)Completed: Well ID# 50 ft' 75 ft- sand-clay
5a.Well Location: 75 fL 90 fL Sand
Johnny Johnson 90 ft. 135 ft- clay
Facility/Owner Name Facility ID#(if applicable) 135 ft, 160 R- sand
OCT
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890 Goins Rd Chadbourn NC 28431 160 fL 190 f- clay it 22
rc ft Inf.3 r' i�
Physical Address,City,and Zip 190 225 sand
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.Certill r n: i
N W 10/1/2022
6.Is(are)the well(s): OPermanent or ❑Temporary SipatureofCertifiedvAVell4to�ritk4e V. 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 8No 15A NCAC 01C.0100 or l5A 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 of the of this record has been provided to the well owner.
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 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:225 (fh) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3 200'and 2@100)
10.Static water level below top of casing:50 ( ) 24a. For AD Wells: Original form to Division of Water Resources (DWR),
If water level is above casing use"+' Information Processing Unit,1617 Mr C,Raleigh,NC 27699-1617
11.Borehole diameter; 6 (in) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
12.Well construction method: Rota'7
Program,1636 MSC,Raleigh,NC 27699-1636
24c.For Water SupXly and Open-L!ooO Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health departmi nt of the county where Installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield Wm)80 Method of test•Air Permit Program,1611 MSC,Raleigh;NI 27699-1611
13b.Disinfection type:Granulated Amount:.1/8 Ibs
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