GW1-2022-09519_Well Construction - GW1_20221017

I;
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: I I
Hugo Rivas 1a.WATER ZONES
Well Contractor Name FROM TO - DESCRIPTION I
ft. ft. 1
3159
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINE&;t(a ticable
Mcpherson Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft 190 fa 2- '"• SCh40 JPVC
Company Name 16.INNER CASING ORTU DING`(aeothermalclosed-too )'
2.Wen Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft ft. �n
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17.SCREEN_
FROM TO TDIAMTER SLOTSiZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 190 it 200 iL o. 8' sch40 pvc
❑Geothermal(Heating/Cooling Supply) nResidential Water Supply(single) ft 190 itn ;;
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑lrri ation ❑Wells>100,000 GPD FROM TO MATERIAL^i EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 it 3 IL cement ;: pour
❑Monitoring ❑Recovery 3 ft 100 ft bentonil:6 tremmie
Injection Weil:
R. ft
❑Aquifer Recharge OGrotmdwater Remediation '
19.SANDIGRAVEL'PACK`ifa livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL , EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 100 ft 200 m gravel#1; pour
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer 2U.DRILLING LOG:attach additional sheets if necessary)
❑Geothermal(Heating(Coolin Return) ❑Other(explain under#21 Remarks) FROM TO DESCRWIION(color,hardness,soil/rock e,grain
si-,au)
9/13/22 o ft. 10 it clay-Sand '
4.Date Well(s)Completed: Well Ew . 10 ft 110 ft- clay j
5a.Well Location: 110 H' 130 iL sand i
Jerry High 130 it 155 fL clay t _t ;
Facility/Owner Name Facility ID#(if applicable) 155 ft 170 ft sand-clay 2622
4660 Red Hill Rd Whitev'rlle NC 28472 17b ft 200 1L sand
Physical Address,City,and Zip ft ft. L
T ,i1
Columbus 2LRE [ARKS L1 '
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certifrc n: t
N w (/�' 9/13/2022
6.Is(are)the well(s): dPermanent or ❑Temporary Signature of Certified ell Contmcto 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 Wed: ❑Yes or ItNo 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and erplain the nature ofthe ofthis record has been provided to the well a)mer.
repair under#21 remarks section or on the back of thisform.
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 Wray also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS 5
9.Total well depth below land surface:200
For multiple wells list all depths ifd different(example-3@200'and 2@I00) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing:40 (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use i
11.Borehole diameter:6 (�,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(WC)
12.Well construction method: Rotary
Program,1636 MSC,Raleigh,NC 27699-1636
24a For Water Sup2l and O en-Lo I 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 We11s producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm)20 Method of test Air Permit Program,1611 MSC,Raleigh,NC i 7699-1611
13b.Disinfection type:Granulated Amount: 1/8 lbs i