GW1--06677_Well Construction - GW1_20241108

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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. 1
2547—A
ft. ft.
NC Well Contractor Certification Number
INC. 15.OUTER CASING(for multi-cased'wells)OR LINER(if ap licable)
REGISTER WELL CO., NC FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 21'0 ft. 2 in, 40 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 QMunicipal/Public 210 ft• 230 ft• 2 in. .016 PVC
Geothermal(Heating/Cooling Supply) !x,Residential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 It HOLE PLUG POUR
0Monitoring ORecovery ft. ft.
-__� l:-__=_Injection.WelL __ ..- ft. ft. -
Aquifer Recharge QGroundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test
POUR
205 ft. 230 ft• #2 GRAVEL POUR
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) n Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type.grain size,etc.)
0 ft• 13 ft, SAND&CLAY
4.Date Well(s)Completed:10-15-24 Well ID# 13 ft• 22 ft. CLAY
5a.Well Location: " 22 __ft• _ 65 ft• SAND/CLAY LAYERS
CHANDRA CARLTON 65 ft. 90 ft• SAND (MED)
Facility/Owner Name - Facility ID#(if applicable) 90 ft• 108 ft. CLAY V'y,C,, ,, 1 7 _ ;,.' ;.`—:,(
182 BROOKS QUINN RD MAGNOLIA NC 28453 108 ft• 120 ft- SAND&CLAY
hysical Address,City,and Zip 120 ft• 136 ft• SAND NOVV 0 8 2024
DUPLIN _4.REMARKS
County Parcel Identification No.(PIN) II`.' -r'`-i'r'hc
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
34.904104 N -78.035512 W /J-O �W 11-4-24
6.Is(are)the well(s)E Permanent or Temporary Signature of fled Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.-Is this a repair to-an existing well: QYes---or 'ENo - with 15A NCAC 02C.0100 or 15A-NC-AG 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: 230 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
Formultiple 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.) 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: 3-7/8 (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.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground-Injection-Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636-MailService Center,Raleigh,NC 27699-1636
i
13a.Yield(gpm) 25 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: 60Z 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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