GW1-2023-01186_Well Construction - GW1_20230127

WELL CONSTRUCTION RECORD For Internal Us,ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: —,v i—g,
V 14.Rom WAT-kR ZO1NE&.
7= .
L
—
Joey Cobarrobias Velasco % —
_F To DESCRIPTION
Well Contractor Name JAN 2 7 Z023 g5 fL TTOfLI Limestone
4055-A 155 fL 195 rt•:t4,0JVq UrA Sandstone
NC Well Contractor Certification Number Prop. M.OUTER CASING(for,,,nsed*111sy, -LINIM, (frap
Dq4,QjB0G FROMI TO T DIAMETER ESS I MATERIAL
fL
-Graigs Well Drilling, LLC ft. I in- Sch 40 Steel
Company 16:INNER-CASING OR TUB11 hernial closed
OSWPWP-22-0138 M FRO TO DIAMETERi RNLATER-TAL
2.Well Construction Permit#: �T �
etc.)
PVC
List all applicable ivellpennies(Le-Cminty.Slate,Mariance,Infection,e +1 117 it- 14
3-Well Use(check well use): ft.
Water Supply Well: FROM TO DIAN.11,TFuz ISLOT SIZE
I ITE� ALATERIM,
LIA.-ricultural 11INfunioilia4'Public 155 it- 195 it. 12 hl.] .010 Sch 40 PVC
ElGeotlicrmal(Heating/Cooling Supply) EIRcsidential Water Supply(single) ft. tt. in.
ClIndustrial/Commercial DResidentitil Water Supply(shared) 18:GROUT
Olirigation MOM TO I MATERIAL— EMPLACEMENTNIETHOD&AMOUNT
Non-'Water Supply Well: 0 ft 4 ft- Hole Plug
—— Gravity 4 bags
ElMonitoring ORecovery 4 fL 60 ft- Quick Grout Pump 13.5 bags
Injection Well: ft. ft.
OArluifer Recharge OGroundwater Renictfiation 19.-SAINDIGRAVE _K(if a 0 plivable:
OAquifer Storage and Recovery ElSalinity Barrier rRON1 TO ft.
t NITATEWE— E:mPLAcr3.lEXTTirTRoD
ft,[]AquiferTcst E]Stormwatcr Drainage — t.ft.
OF-xperimental Technology OSubsidence Control fL ft.
�.220.`DRIL G10GIatta
ElGeothermal(Closed Loop) OTr-acer FROM TO TENSCRIPTION(E I-,hard.—.s.itirml,ty rain sac.etc❑ )
Geothermal(Heating/Cooling Return) 00ther(explain under,121 Remarks)-, 0 ft- 27 ft. Black Clay
4.Date Well(s)Completed: 1/25/23 N 27 ft' 38 ft.
Well IDN Silt
5a.Well Location: 138 f' 65 ft- Course Sand
Jim McCormick 65 'L 95 ft. Mud Rock
Facility/OwncrName Facility IDf/(if applicable) 95 'L 110 ft- Limestone
4601 NEW JACK RD , WM, NC, 28409 110 ft- 150 fL Mud Rock
fL 155 fL
Physical Address,City,and Zip 150 Rock 155-195 Sandstone
New Hanover
R07213-007-033-000 11 OOLL W Tk,E� _ PE C_ _Aeao_� VA At-
T
County parcel Identification No.(PIN) I r 1 -1 -5. A-VUA VU I
ow,Flom in'rOSI.-.0`:S CAU-!b 4D L i tJ Q_ Pe,
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
4(ifwell field,one lat/long is sufficient) 22.Certificatio0: IS STc C � Fb 491 10:5 LOT
34 9 10 77 51 40 VARIA(%SU-1 %S6oab,
N
- W c7o. "coo 1/25/23
Signaffra of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or OTemporary
By signing this form.I hereby cerfi57 that the well(y)was(aere)constructed in accordance
with 15ANCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this repair to an existing well: OYes or R]No COPY of Bus record has been provided to the well owner.
If this is a repair,fill out;noun well construction information mid explain the nature of the
repair undw P21 remarks section or on the back ofthisform 23.Site diagram or additional well details-
8.Number ofivells constructed: 1 You may use the back of this page to provide additional well site details or well
Forniultiple byection or non-vtatersupply walls ONLYlvith the same construelion,yoz,can construction details. You may also attach additional pages.if necessary.
Submitoneform SUMNUTTAL INSTUCTIONS
9.Total well depth below land surface: 195 ft.) 24a. For All Wells Submit this form within 30 days of completion of well
Forniultiple wells list all depilis ffdi#Brent(example-3@200'and 2@1001) construction to the following:
10'Static water level below top ofeasing- 9 (ft-) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"i 1617 INUI Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8 24b.For Infection Wells ONLY: In addition to sending the form to the address in
12.Well construction method: Mud Rotary 24a above: also submit a copy of this form within 30 days of completion of well
(ic.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,I'Inderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(_-pm) 25 Method oftest: Air 24c.For Water Supply&Injection Wells:
13b.Disinfection type: HTH 2# Also submit one copy of this form Within :10 days of completion of
Amount. well construction to the county health department of the county where
constructed.
Forni,Gw-1 North Carolina Department of Environment and Natural Resources-Division of Water Rcso urces Revised August 2013