GW1--05263_Well Construction - GW1_20240906

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WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Well Contractor Information:
Hugo Rivas 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
fr. ft.
3159
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-eased wells)OR LINER(if ap licable)
Mcpherson Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 n' 195 ft. 2 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): fr. ft In.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 195 ft- 205 ft. 2 in- 8 sch40 pvc
❑Geothermal(Heating/Cooling Supply) I(Residential Water Supply(single) . ft. 195 in.
0 Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
0 Irrigation ❑Wells>100,000 GPD FROM TO _ MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 3 cement pour
ft-❑Monitoring ❑Recovery 3 ft- 100 ft. bentonite tremmie
Injection Well:
It. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test OStormwater Drainage 100 ft. 205 ft. gravel#1 pour
❑Experimental Technology OSubsidence Control ft. ft.
❑Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 30 fr. sand _
4.Date Well(s)Completed: 8/1/24 Well ID# • 30 ft. 95 ft- clay
5a.Well Location: 95 ft- 195 ft* sand/clay
_
Wilverine Northon 195 ft- 205 ft- sand
Facility/Owner Name Facility ID#(if applicable) ft. It. �i� 1."
901 Joe Pivet Rd Chadbourn NC 28431 ft. ft. -SFr)
.L- ,fr •L)
Physical Address,City,and Zip •
ft. ft. �1 C N O s 2024
Columbus 21.REMARKS
County Parcel Identification No.(PIN) 1f1�GrR' r1 Pre";
QY9teyj] `
5b.Latitude and longitude in degrees/minutes/seconds or decim degrees: �w �
al
(if well field,one lat/long is sufficient) 22.Ce ' cation:
N w �/ 8/1/2024
6.Is(are)the well(s): (JPermanent or ❑Temporary Si± Cecifi '
ure ell ontrector Date
By signing this form,I hereby cern))'that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 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 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:205 (fL)
For multiple wells list all depths if different(example-3®200'and 2®100') Submit this GW-I within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 25 (ft.)
If water level is above casing,use'+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
24b.For Inleetlon Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter:8 (�,)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rota'1�/ 24e.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.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