GW1--05265_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 Certi6c❑tiun Number IS.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
Mcpherson Well Drilling FROM TO DIAMETER _ THICKNESS MATERIAL
Company Name 0 it' 208 ft• 4 in. sch40 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 ❑Municipal/Public 208 iL 228 ft- 4 in. 12 sch40 pvc
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft• 208 ft• in.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
❑hrigation ❑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(if applicable)
DAquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 100 it 225 ft• gravel#1 pour
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(mbar,baldness,eon/rock type,grain size,etc.)
0 ft. 30 ft• sand
4.Date Well(s)Completed: 7/29/24 Well ID# 30 ft• 60 ft, sand
5a.Well Location: 60 ft. 2136 ft- clay �' _
Amanda Brown Rescue Construction 205 ft 228 it• sand l \ r '`
Facility/Owner Name Facility ID#(if applicable) it' ft.
49 Stacy Ln Tabor City NC 28463 ft• it. SEP 0 6 2024
Physical Address,City,and Zip ft. ft Inter.hires P'r',t
aAt
Columbus 21.REMARKS pyyp# '�t
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.Cert.'cation: /���"'V-
N "' O. 7/29/2024
6.Is(are)the well(s): 1JPermanent or ❑Temporary Signature of enilicd We otmactor Date
By signing this form./hereby certify that the well(s)war(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ft No 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#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 I GW-I 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:228 (it') Submit this GW 1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3®2 )00'and 2@100
10.Static water level below top of casing: 50 ( ) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use•'+"
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: Rota'1 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 GPI):Copy to DWR,CCPCUA
i3a.Yield(gpm) 60 Method of test: Air
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Granular Amount: 1/8 lbs