GW1--06365_Well Construction - GW1_20241025

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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
ft. ft.
NC Well Contractor Certification Number .15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
REGISTER WELLCO., INC. FROM , TO DIAMETER THICKNESS MATERIAL
0 ft• 205 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.
17.SCREEN
Water Supply Well:
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
I Agricultural DMunicipal/Public 205 ft• 225 ft• 04 .016 PVC
®Geothermal(Heating/Cooling Supply) iDResidential Water Supply(single) ft, ft. in.
®i Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 it 20 it HOLE PLUG GRAVEL
NiMonitoring flRecovery ft. ft. ,
-- --- Injection Well:- --- -- --- -- - - - - - - - --- -
ft. ft.
*Aquifer Recharge QGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
®!Aquifer Storage and Recovery D Salinity Barrier FROM TO - MATERIAL ! EMPLACEMENT METHOD
a Aquifer Test ID Stormwater Drainage 204 ft 225 ft• GRAVEL(2) POUR
WI Experimental Technology ID Subsidence Control ft. ft.
®!Geothermal(Closed Loop) IDTracer 20.DRILLING LOG(attach additional sheets if necessarv)
Geothermal(Heating/Cooling Retum) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soilfrock t ,¢ram siiiceth.r'° ' :`-1
0 ft. 13 ft. SAND IF-`�b..-,:.r .:2 . ? .:
4.Date Well(s)Completed:8/20/24 Well ID# 13 ft• 21 ft SAND&CLAY OCT 9 `. 2024
5a.Well Location: 21 ft. 29 ft. CLAY
WARREN BATTS 29 ft. 40 ft• SAND&CLAY Info ran; ',in!
L' 3
Facility/Owner Name Facility ID#(if applicable) 40 ft. 58 ft SAND (MED/COURSE)
BROOKS QUINN RD 58 ft. 63 ft. SAND&CLAY
Physical Address,City,and Zip 63 ft• 105 ft• SAND (MED)
MAGNOLIA, NC 28453 21.-REMARKS
County I , Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
34.905838 N -78.035495• W /_1--_O 77,1,( / 10/15/24
6.Is(are)the well(s){]Permanent or Temporary Signature of Ce ed Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is-this-a repair to an existing-well:---JjYes or IX No with 15A NCAC 02C.0100 or 15ANCAC 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#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 site details or well
construction,only 1 GW-1 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: 235 FT ft.
P ( ) 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:32 FT (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 Injection 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
(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 Method of test:AIR 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: 8 OZ 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
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