GW1--02020_Well Construction - GW1_20240401

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Hugo Rivas 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
3159 ft.
NC Well Contractor Certification Number 15.OUT_ER CASING(for multi-cased wells)OR LINER(if ap licable)
Mcpherson Well Drilling `FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 185 ft- 4 sch40 pvc
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: _F20M TO DIAMETER TIllCKNESS MATERIAL
- List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 185 ft- 205 ft- 4 in' 12 sch40 pvc
❑Geothermal(Heating/Cooling Supply) 19Residential Water Supply(single) ft. 185 ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
T
❑irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 3 ft- cement pour
❑Monitoring ❑Recovery 3 ft- 100 ft- bentonite tremmie
Injection Well:
ft. ft.
❑Aquifer 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. 205 ft- gravel#1 pour
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
0• ft. 10 ft. sand
4.Date Well(s)Completed:2/2/24 Well ID# 10 ft- 40 ft- clay [:� "" ,�,
Sa.Well Location: 40 ft- 65 ft- sand ""�f ° -' , ' �
Christian McDuffie 65 ft- 120 ft- clay APR ) 1 2021
Facility/Owner Name Facility ID#(if applicable) 120 ft- 135 ft. sand
135 ft. 190 ft' claylI i ri• ;,a�>...sS.;i I yent
1360 Pameter Rd Hallsboro NC 28442 ;,.tares..,s.
Physical Address,City,and Zip 190 ft- 205 ft. sand `i`y
Columbus 21.REMARKS
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.Cer'ft Don:
N " d 11.-/-- 2/2/2024
6.Is(are)the well(s): CIPermanent or DTemporary Si tore of C hied Well C tar 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 I5A NCAC 02C.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 explain the nature of the of this 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 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:205 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@100)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 50 (ft') Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use•'+"
11.Borehole diameter 8 (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 Supply and Open-Loop 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 Wells producing,over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 60 Method of test:Air Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Granulated Amount: 1/8 lbs