GW1--05259_Well Construction - GW1_20240906

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. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a cable)
Mcpherson Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 192 ft. 4 'n• 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,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. hi.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural ❑Mun»cipal/Public 192 it 212 it. 4 in' 12 sch40 pvc
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft• 192 ft• is
❑lndustrial/Cotmnercial ❑Residential Water Supply(shared) IS.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- 100 ft- bentonite tremmie
Injection Well: ft.
DAquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
DAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test ❑StormwaterDrainage 100 ft 212 it gravel#1 pour
DExperimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rocktype,grainere.l
0 ft. 80 ft clay
4.Date Well(s)Completed: 8/1 4/24 Well ID# 80 ft. 105 ft- sand
5a.Well Location: 105 ft' 170 ft' clay
Terry Spaulding 170 ft- 190 ft- sand/day ,-_ 4,
Facility/Owner Name Facility ID#(if applicable) 190 ft 212 ft- sand k'. `r 1 Li7
274 Rico Rd Clarkton NC 28433 ft. ft. SE P i1 6 2024
Physical Address,City,and Zip ft. ft.
Columbus 21.REMARKS --inbfirsaliefl harm digge:nr um*
County Parcel Identification No.(PIN) ��
OG
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficiem) 22.Ce ification:
N W ,^e�;0�� I
4 8/14/2024
6.Is(are)the well(s): nPcrmanent or ❑Temporary Sign:ture4 Cerertiti ell Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or t!INo ISA NCAC 02C.0100 or ISA 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#2!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-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:212 (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')
10.Static water level below top of casing:50 ( ) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
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
(i e.auger,rotary,cable,direct push etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
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
Permit Program,1611 MSC,Raleigh,NC 27699-161 I
13a.Yield(gpm) 80 Method of test: Air
13b.Disinfection type: Granular .Amount: 1/8 lbs