GW1--04923_Well Construction - GW1_20240816

IPrint Form I
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
'!,LOYD MARES 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2547-A ft. ft.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
REGISTERWELL CO, INC. FROM TO DIAMETER THICKNESS I MATERIAL
Company Name 0 ft• 135 ft- 4 in. .40 I PVC
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,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 0\lunicipa1/Public 135 ft• 150 ft• 4 In• .016 PVC
Geothermal(Heating/Cooling Supply) Ill Residential Water Supply(single) ft. ft. in.
Industrial/Commercial O.Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft• HOLE PLUG POUR
Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
ft.
Aquifer Recharge InGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage 133 ft. 150 ft. GRAVEL#2 POUR
Experimental Technology 0 Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rocka pe,grain size.etc.)
0 ft. 27 ft. CLAY
4.Date Well(s)Completed:06/27/24 Well ID# 27 ft. 35 ft. SAND AND CLAY
5a.Well Location: 35 ft. 58 ft. SAND
AUSTIN BOONE 58 ft• 75 ft• SAND AND CLAY
Facility/Owner Name FacilitylDll(ifapplicable) 75 ft• 76 ft. ROCK 12 IN
BRICES STORE RD ROSE HILL NC 28458 76 ft• 97 ft• SAND AND CLAY •? . ice.
Physical Address,City,and Zip 97 ft. 98 ft. ROCK 10 IN • v I.-{ix,
DU%PLIN 21.REMARKS 'i 1
1IG 7 g 2024
County Parcel Identification No.(PIN) t�
. a,,..
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -,A"r-• :,,. '* Ud
(if well field,one lot/long is sufficient) 22.Certification: v,3
34.823909 N -78.065634 W ora LL_D 7 /E2 08/13/24
6.Is(are)the wellXs) Permanent or TemP ry Signature of Ceilffiedll Contractor Date
By signing this form,I hereby certifi,that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: piles or XONo with/SA NCAC 02C.0100 or/SA 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: 150 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing:27 (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 SuDDiv& 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-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

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