GW1--02022_Well Construction - GW1_20240401

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: f
1.Well Contractor Information:
Hugo Rivas 14.WATER ZONES ,
Well Contractor Name FROM . TO DESCRIPTION
3159 ft. ft.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Mcpherson Well Drilling -FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 90 ft. 2 in" sch40 pVC
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Stale,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. tt. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 90 ft- 100 ft. 2 in. 8 sch40 PVC
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. 90 ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑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, 50 ft- bentonite tremmie
Injection Well: -
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 50 ft' 100 ft- gravel#1 pour
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
0 Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,sail/rack type grain size,etc.)
0 ft- 15 ft- sand
4.Date Well(s)Completed:2/6/24 Well ID# 15 ft- 40 ft- clay
5a.Well Location: 40 ft 50 ft- sand (.:: ':,^ ,
4 7-"A
Elvin Escobar 50 ft- 85 ft- clay
Facility/Owner Name Facility ID#(if applicable) 85 ft 100 ft- sand 4PR 0 1 y
2074.
71 Pio Andlyncis Ln Elizabethtown NC 28337 ft ft.
Physical Address,City,and Zip
ft. ft. true. Ye2ti,.�l ,-'''"':,s„&:,,61 u '
Bladen 21.REMARKS ` '•I '
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.Ce if ation' 4
N W ������ 2/6/2024
6.Is(are)the well(s): Permanent or OTemporary
Si stature of rtifiedSf Contractor Date
By signing this form,'hereby cerdbi that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or inNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out(mown well construction information and explain the nature of the of this record has been provided to die 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-i 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: 1 00 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdif�erent(example-3@200'and 2@I00)
30 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (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)20 Method of test:Air Permit Program,1611 MSC,Raleigh,NC 27699-1611
Granulated 1/8 lbs
13b.Disinfection type: Amount: