GW1--05869_Well Construction - GW1_20241001

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Lloyd Mares 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
2547-A fL ft.-
NC Well Contractor Certification Number Inc. 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Register Well Co., c FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 103 ft. 4 '", .40 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. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 0Municipal/Public 103 ft. 123 ft• 4 in' .016 pvc
Geothermal(Heating/Cooling Supply) ©Residential Water Supply(single) ft. ft. in.
Industrial/Commercial 0 Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. hole plug pour
Monitoring 0 Recovery ft. ft.
Injection Well: fL ft.
Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recover) ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ❑Stormwater Drainage 102 ft- 123 ft. gravel pour
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size•etc.)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) 0 ft. 9 ff clay
4.Date Well(s)Completed:08/19/24 Well ID# 9 ft' 17 ft' sand and clay
5a.Well Location: 17 fL 43 ft' clay rr
Eric Simpson 43 ft- 65 f. sand medium t .` * , f
Facility/Owner Nang Facility lD#(if applicable) 65 ft. 71 ft sand and clay +
84 Jesse Moore Ln Ivanhoe NC 28447 71 ft• 72 ft. rock 12 in OCT 0 ' 124
Physical Address.(in and/a, 72 ft. 77 ft. sand
Pender 21.REMARKS s•_.,;
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
34.613156 N -78.122041 W 1-.1--O 71/1.4/ 8/19/24
6.Is(are)the well(s)OPermanent or Qll'emporary Signature of 5ed Well Contractor Date
By signing this form,I hereby certify that the wel(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or XONo with 1SA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under 421 remarks section or on the hack 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 site details or well
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 123 (.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing:20 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 3/4 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
rotary above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 50(80) Method of test:air 24c. For Water Sun&ly& Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13h.Disinfection type: hth Amount: 8oz completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

CiSTOMER: ADDRESS:
CKNESS FORMATION THICKNESS FORMATION
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