GW1-2022-09522_Well Construction - GW1_20221017

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information:
Hugo Rivas 14.WATER ZONES
Well Contractor Name FROaf TO DESCRIPTION'
ft. ft.
3159 f,
NC Well Contractor Certification Number 15.'OUTER CASING Cor mold cased we
Ils)OR LINER U e doable
IVII✓pherSon Well Drilling FROM TO DIAMETER THICINSESS MATERIAL
Company Name 0 ft 175 ft 2 i:* 1SCh40 PVC
16.INNER CASING;OR TUBING(eothermat closed-loop).
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits fl.e.UIC,County,State,Variance,etc.) ft. ft.
3.Well Use(check-well use): ft. IL im
Water Supply Well: 17.SCREEN
FROM TO DIAMETER ''SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Munieipal/Publie 175 It• 185 It. 2 in. 8 seh40 pvc
❑Geothermal(Heating/Cooling Supply) InResidential Water Supply(single) ft• 175 ft. 1D '
❑lndustrial/Commercial ❑Residential Water Supply(shared) `18.GROUT
❑hri ation ❑Wells>100,000 GPD FROM I TO MATERIAL• EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 m 3 IL cement pour
❑Monitoring ❑Recovery 3 ft. 100 ft' bentonite tremmie
Injection Well:
tt. fL
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK rf a lieabie.
OAquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL'- AusIPLACEmENTmETHrm
❑Aquifer Test ❑StormwaterDrainage 100 ft- 185 ft- gravel#1 1pour
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach addidonal'sheets if necessary)
FROM TO - DESCRIPTION,color,hardness,soillrock type,grain size,eta)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 10 ft• Clay
4.Date Well(s)Completed: 9/9/22 Well ID# 10 ft 65 ft. clay
5a.Well Location: 65 It• 75 It, Clay '• -
Jonathan Worley 75 ft- 135 fL sand
Facility/Owner Name Facility lD#(ifapplicable) 135 It 145 It Clay
ncT
1979 Soles Rd Whiteville NC 28472 145 ft. 155 CL clay
Physical Address,City,and Zip 155 It, 185 It sand
Irs{
Columbus 21.REMARKS UIL4
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Cc_'t ation:
N W 9/9/2022
6.Is(are)the well(s): MPermanent or ❑Temporary Signattre ofCcrtifd Well Contractor 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 ONo 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,JHl out known well construction information and erplain the nature of the ofthis 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: 185 (ft)
For multiple wells list all depths ifdperent(example-3@200'and 2@100) Submit this GW-1 within 30 days of-well completion per the following:
10.Static water level below to of casing 50 ( ) 24a. For An Wells: Original formi to Division of Water Resources (DWR),
Ifwater level is above casing,use"+" Information Processing Unit,1617 MSC;Raleigh,NC 27699-1617
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11.Borehole diameter•6 UC)
(in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(I
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rota'] 24c For Water Supply and Open-Loop Geothermal Return Webs: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 Webs ucing over i100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm)20 Method of test:Air prod
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type:Granulated Amount: 1/8 lbs
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