GW1--05260_Well Construction - GW1_20240906

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well('ontractor Information:
Hugo Rivas 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
3159
ft. It.
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. 200 ft- 4 in, sch40 pvc
Company Name 16.INNER CASING OR TUBING(geothermal closed400p)
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 SITE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 200 ft 220 ft 4 tn- 12 sch40 PVC
❑Geothermal(Heating/Cooling Supply) CIResidential Water Supply(single) R. 200 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
OMonitoring ❑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 OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 100 ft' 220 ft gravel#1 pour
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) OOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,Yardman stanch type snis cia etc.),
0 tt• 20 ft sand
4.Date Well(s)Completed: 8/12/24 Well ID# 20 ft- 75 ft- clay
5a.Well Location: 75 ft 95 ft- sand 4 r i
Lawanda Bentley 95 ft- 195 ft- day/sand 1 ‘0-L.L:; f L
Facility/Owner Name Facility Rbl(if applicableI 195 ft- 220 ft- sand SEP 0 6 2024
292 Green Meadow Ln Whiteville NC 28472 ft ft.
Physical Address,City,and Zip ft. ft. Ifl/OfA.G,ste l j let ,
Columbus 21.REMARKS "Nadi Q
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.('er Yication:
N W 10 i &/,- 8/12/2024
6.Is(are)the well(s): nPermanent or ❑Temporary rgoature fCeniticd elIContractor Dare
By signing this form.I hereby terrify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or elNo 1SA NCAC 02C.0100 or I SA 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 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:220 (D) Submit this GW 1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example- @a 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 Inject on Wells:Copy to DWR,Underground Injection Control(IUC)
Rotary
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 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
Permit Program,1611 MSC,Raleigh,NC 27699-1 61 1
13a.Yield(gpm)80 Method of test:Air 13b.Disinfection type: Granular Amount: 1/8 lbs