GW1--04922_Well Construction - GW1_20240816

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
• ' 1.Well Contractor Information:
'LLOYD MARES 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
ft.
2547-A ft.
ft. ft.
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
REGISTERWELL CO, INC FROM TO DIAMETER THICKNESS M ATE RAAl
0 ft. 200 ft. 4 in• .40 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
Z.Well Construction Permit#: FROM TO DIAMETER THICKNESS 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.
W 17.SCREEN
Wpp e :
FROM TO DIAMETER SLOT SIZE THICKNESS \t ATERIAL
Agricultural IDMunicipal/Public 200 ft• 220 ft. 4 in. .016 PVC
Geothermal(Heating/Cooling Supply) p Residential Water Supply(single) ft. ft. in.
Industrial/Commercial 0 Residential Water Supply(shared) 18.GROUT
Irrigation FROM _ TO \IATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft- HOLE PLUG POUR
Monitorinc ®Recovery ft. ft.
Injection NA ell: •
rt. ft.
Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL _ EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage 199 ft• 220 ft. GRAVEL#2 POUR
Experimental Technology (]Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) 0 ft. 5 ft SAND
4.Date Well(s)Completed:08/1/24 Well ID# 5 ft. 15 ft. CLAY
Sa.Well Location: 15 ft' 34 ff• SAND AND CLAY
TEVAN SAVAGE 34 ft- 85 ft- SAND MEDIUM
Facility/Owner Name Facility 1Db(if applicable) 85 ft- 96 ft- SAND AND CLAY MEDIUM
767 HALLSVILLE RD BEULAVILLE NC 28518 96 ft. 105 ff. CLAY
Physical Address,City.and lip 105 ft. 135 ft• SAND AND CLAY
DUPLIN 21,REMARKS
County Parcel Identification No.(PIN) i}I r 1 Z024
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ll U
(if well field,one lat/long is sufficient) 22.Certification: Ir45 r js•,; L r' .ts -,1 tJ.*
34.913414 -77.799334 ��, i;'r,�:- _. •.
0109 ���� 08/01/24
6.Is(are)the weil(s)J% Permanent or DTemporary Signature ofCe fed Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or XQ ti o with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy 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 site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 220 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For mu!nide wells list all depths rfdif'erent(example-3@200'and 1@100) construction to the following:
10.Static water level below top of casing:57 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 3/4 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
ROTARY above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 50 (80) Method of test:AIR 24c. For Water Snooty& Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: 6 OZ completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

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