GW1-2022-09518_Well Construction - GW1_20221017

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: j
Hugo Rivas KWATERZONEs
Well Contractor Name FROM TO DESCRIPTION
3159 ft ft. �
fL ft.
NC Well Contractor Certification Number -15.OUTER CASING(for multi-cased wills OR LINER d a"likable'
McPherson Well Drilling FROM TO DIAMETER, T®CkNESS MATEtunl.
Company Name O ft. 215 ft 2 ;;1°` SCh40 pvc
16.INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit#: FROM To DIAMETEW THICKNESS MATERIAL
List all applicable well construction permits#.e.UIC,County,State,Variance,etc.) ft it. ;in
3.Well Use(check well use): a R. (in.
Water Supply Well: 17.SCREEN
FROM TO I DIAMETER "SLOT SIZE "TRIMNESS MATERIAL
❑Agricultural ❑Municipal/Public 215 It- 225 IL 2 In' Isch40 JPvc
[]Geothermal(Heating/Cooling Supply) InResidential Water Supply(single) ft- 215 ft 1O
❑Industriat/Commercial ❑Residential Water Supply(shared) -
pP yhd( ) 18.GROUT
❑hri ation ❑Wells>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 bentonit'e tremmie
Injection Well:
iG iw
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL. I EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 100 ft. 225 ft. gravel#'1 1POUr
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG'attach additional'sheets ifnecessary)
FROM TO DESCRIPTION.(color,hardness,sowrock typz grain sis'etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 35 ft- sand 1;
4.Date Well(s)Completed:9/27/22 Well ID# 35 ft. 90 ft Clay !!
5a.Well Location: 90 ft. 110 °- sand
Carolyn Blanks 110 fL 180 fL clay
Facili /Owner Name Facility ID# ifa likable ft ft- t "' J
ty ty ( applicable) 180 190 sand ��.+'.�,.?�.� " ' ' r�°�
5280 Hallsboro Rd N Whiteville NC 28472 190 ft 205 ft clay ,
Physical Address,City,and Zip 205 fL 225 ft. sand 2022
Columbus 21.REN ARKS
County Parcel Identification No.(PIN)
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Ce e, 'on:
N w p ! 9/27/2022>=
6.Is(are)the well(s): MPermanent or ❑Temporary Signaturf of Cettifi ell Contra r Date
By signing this form,I hereby certify that the will(s)was(were)constructed in accordance with-
7.Is this a repair to an eidsting well: ❑Yes or MNo 15A NCAC 02C.0100 or ISA 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 ofthis record has been provided to the well owner-
repair under#l1 remar/a section or an the back of this farm.
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 (ft)
For multiple wells list all depths ifdiff'erent(example-3@200'and 2@100) Submit this GW-1 within 30 days ofiwell completion per the following:
50 24a. For All Wells: Original form!:to,Division of Water Resources (DWR),
10.Static water level below top of casing: (it) Information Processing Unit;1617 MSC,;Raleigh,NC 27699-1617
If water level is above casing,use
6 24b.For Injection Wells:Copy to DWR,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 depattmcut of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing ovl r 100.000 GPD:Copy to DWR,CCPCUA
Permit Pmgtam,1611 MSC,Raleigh,N i 27699-1611
13a.Yield(gpm) Method of test: I r f
13b.Disinfection type:Granulated Amount: 1/8 Ibs
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