GW1-2021-00478_Well Construction - GW1_20211222

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Hugo Rivas
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
3159
ft, ft.
NC Well Contractor Certification Number
15 Q1artti7tl-cane -, URUIIri1 �4 t
Mcpherson Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0y ft- 228 ft- 4 / 1n stch�40�s pvc
Company Name F,1 ___ ' RsjApf
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:
FROM TO DIAMETER SLOT SIZE THICKNESS y-MATERIAL
❑Agricultural ❑Municipal/Public 228 ft- 248 ft- 4 in. 10 Sch40 pvc
❑Geothermal(Heating/Cooling Supply) [!]Residential Water Supply(single) ft• 228
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑Irri ation ❑Wel►s>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 3 ft. cement pour
❑Monitoring ❑Recovery 3 rt• 100 ft- bentonite tremmie
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
9 RItP�_1#l/L#ft 1 ii ,$A�iC"if fc3i e a ,r_
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL x EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 100 f` 248 tt• gravel#1 pour
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20>)`2ZTlGLTti"_ '" aiZhdiClonatslteets#ttecaa _,r:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
0 ft. 80 fc. clay
4.Date Well(s)Completed: 1 1/12/21 Well ID# 80 f` 110 rt• sand
5a.Well Location: 110 f` 155 tf clay
Glen Mckeithen 155 f` 175 f` sand
Facility/Owner Name Facility ID#(if applicable) 175 ft• 190 ft- clay 2
6823 Lisbon Rd Clarkton NC 28433 190 f` 200 ft• sand
Physical Address,City,and Zip 200 ff 210 ff clay
Bladen
County Pared Identification No.(PIN) 210-248 sand
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certi cation:
N W �AL
6.Is(are)the well(s): InPermanent or ❑Temporary Sign ure of Ce iied W l ContrVactor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 15A 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.SUBMTPTAL INSTRUCTIONS
9.Total well depth below land surface: 248 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells fist all depths if dierent(example-3@200'and 2@100')
50 24a. For All Wells: Original form to Division of Water Resources (DWR),
tf Static water level below top of casing: (fL) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(TUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rotary 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.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) 70 Method of test: Tr
13b.Disinfection type: granular Amount: 1/o
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018