GW1--06678_Well Construction - GW1_20241108

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,_ ELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
54.
1.Well Contractor Information:
LLOYD MARES 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2547-A ft. ft. I
ft. ft. I
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
REGISTER WELL CO., INC. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 180 ft. 4 in• .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. I in.
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
M Agricultural 0 Municipal/Publ ic 180 ft. 200 ft. 4 in. .016 PVC
®Geothermal(Heating/Cooling Supply) IX Residential Water Supply(single) ft. ft. in.
it Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
• Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 it 20 ft• HOLE PLUG POUR
®Monitoring Recovery ft• . ft. 1
Injection Well: ft. ft.
111I Aquifer Recharge IDGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
$Aquifer Storage and Recovery D Salinity Barrier FROM - TO MATERIAL EMPLACEMENT METHOD
®Aquifer Test DStormwater Drainage 179 ft 200 ft. #2 GRAVEL POUR
®Experimental Technology 0Subsidence Control ft. ft.
$Geothermal(Closed Loop) Ell Tracer 20.DRILLING LOG(attach additional sheets if necessary)
I Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
0 ft. 5 ft. SAND
4.Date Well(s)Completed: 10/8/24 well ID# 5 ft. 18 ft. CLAY . .+ .t-,,,tL._ . `r' t„
5a.Well Location: 18 ft. 25 ft. SHELL &CLAY NOV 0 8 2024
ELLIE PARKER ' 25 ft. 29 ft. CLAY '
ft ft. 161.°:`•i,6, ti -'-.._`s s :7 t'::Y
Facility/Owner Name Facility ID#(if applicable) 29 45 ROCK;&CLAY .. -• -
281 MAREADY,RD CHINQUAPIN, NC 28425 45 ft 61 ft. CLAY
Physical Address,City,and Zip 61 ft. 63 ft. ROCK(SOFT 2') . .
D U P L I N 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sufficient) 22.Certification:
34.799969 N -77.763513 W L OVP -N /5 . 11/4/24
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6.Is(are)the well(s){JPermanent or OTemporary Signature ofCed Well Contractor Date
By signing this form,I hereby cert/that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: _',Yes or DNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill Out known well construction infonnation.and explain the nature of the _ copy of this record has been provided to d,e.si'ell owner.
repair under#21 remarks section or on the back of this form. - r
23.Site diagram or additional well details:
You For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same 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: 200 (ft•) 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:36 (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.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) 15 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: 8OZ completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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