GW1-2022-09520_Well Construction - GW1_20221017

I.
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Hugo Rivas 14.WATER ZONES F'
FROM TO DESCRIPTIONI
Well Contractor Name
3159 i.
NC Well Contractor Certification Number 15.OUTER CASING'(for multi-cased wens OR LINER o ncable
Mcpherson Well Drilling FROM To DIAMETER'. THICKNESS mATERIAL
0 fa 1230 ft 2 in' sch40 pVC
Company Name 16.INNER CASING OR TUBING(eotbermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER . THICKNESS I MATERULL
List all applicable well construction permits(i.e.UIC,County.State,Variance,etc.) % iL 'in.
3.Well Use(check well use): ft 2 in '
Water Supply Well: FROM SCREEN17. TO DIAMETER -SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 230 f° 240 tt. 2 tn' 8 sch40 pvc
❑Geothemial(Heating(Cooling Supply) OResidential Water Supply(single) ft. 230 tr in. ':
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
131rri lion ❑Wells>100,000 GPD FROM I To MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 n 3 cement pour
17Monitoriug ❑Recovery 3 ft. 100 t4 bentonite tremmie
Injection Well:
ft. It. ,
OAquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable),
❑Aquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 100 ft. 240 ft. gravel#,1 pvc
❑Experimental Technology ❑Subsidence Control ft. R
❑Geothermal(Closed Loop) []Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remark].) FROM TO DESCRIPTION color,hardne&%soil/rock type,grain"etc.)
0 rt 20 fL sand j
4.Date Well(s)Completed: 9/8/22 Well m# 20 rc 60 ft. clay
5a.Well Location: 60 fL 95 IL sand ;, P:?. %?t
Austin/Allyssa Storms 95 ft. 140 ft: clay
Facility/Owner Name Facility W#(if applicable) 140 ft' 160 ft' sand OCT 1 7
20
364 Walters Rd Bladenboro NC 28420 160 ft, 220 fL clay
d...
Pro
Physical Address,City,and zip 220 ft. 240 fL sand ' ,.,, "72''1'•1 Ur
Columbus 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Ce anon:
N W - !PA 9/8/2022
6.Is(are)the well(s): Permanent or ❑Temporary Si race of Cc ed well Co ct r 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 Mo 15A NCAC 02C.0100 or 15A NCAC 02C.b200 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 lite 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 I 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:240 (ft) Submit this GW-1 within 30 days o well completion per We following:
For multiple wells list all depths if different(example-3 a200'and 2@1001
10.Static water level below top of casing:50 (fL) 24a. For An Wells: Original form,to Division of Water Resources (DWR),
Information Processing Unit, MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" i
11.Borehole diameter:6 (in,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rotary 24c.For Water Suvvlv and Oven-"op Ove.."op Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where insta ed
I
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over100,000 GPD:Copy to DWR,CCPCUA
13a.Yield Wm)30 Method of test:Air Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type.Granulated Amount: 1/8 lbs