GW1--05262_Well Construction - GW1_20240906

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Hugo Rivas 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
3159 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(If ap Usable)
Mcpherson Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 177 II. 2 in. Isch40 pvc
Company Name
16.INNER CASING OR TUBING(geothermal dosed-loop)
2.Well Construction Permit#: FROM TO DLAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U/C,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 177 ft. 187 ft. 2 is 8 sch40 pvc
❑Geothermal(Heating/Cooling Supply) ClResidential Water Supply(single) n. 177 ft• in.
0 Industrial/Commercial ❑Residential Water Supply(shared) 1&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. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK Of applicable)
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL _ EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 100 ft• 187 f'• gravel#1 pour
❑Experimental Technology OSubsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) PROM TO DESCRIPTION(Mar,hardness,soil/rock type,grain size,etc.)
0 ft. 40 ft• sand/clay
4.Date Well(s)Completed: 8/2/24 Well ID# 40 ft. 130 ft• clay
5a.Well Location: 130 ft• 155 ft• sand
Johnny Johnson 155 ft• 165 ft• day f i i.—`.
_ jam.
Facility/Owner Name Facility lD#(if appl icablc) 165 ft• 87 ft- sand ,"! i�1... .
37 Magnolia Dr Whiteville NC 28472 ft• ff. SLP 6 6 2024
Physical Address,City,and Zip ft. ft.
Columbus 21.REMARKS l,�yfr ft9 wit
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Ist/long is sufficient) 22.Cert.(cation:
N W e e�i J 8/2/2024
6.'stare)the well(s): OPermanent or OTemporary Signature o ified Well Contractor Date
By signing this form,/hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or eiNo iSA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill our 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: 1 87 (fL)
For multiple wells list all depths if different(example-3( 200'and 2(4)100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 50 (ft-)
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 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 27699-1611
13a.Yield(gpm) 20 Method of test:Air
13b.Disinfection type: Granular Amount: 1/8 lbs