GW1-2021-00491_Well Construction - GW1_20211222

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Hugo Rivas ,. �Y
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
3159
ft. ft.
NC Well Contractor Certification Number
Mcpherson Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft 170 ft- 2 in. sch40 1pvc
Company Name r ��N1iRt�'€iH�it/dR=-`Tl3�TCi.'�nfhe�ni9lF.Iossesl-I
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): yyy fit. y( ft. in.
�Vl(�1Ctk f..yj roiF fug?:£ ��.
Water Supply Well: FROM TO DIAMETER`SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Pubhc 170 ft. 180 ft- 2 in. 8 sch40 pvc
❑Geothermal(Heating/Cooling Supply) InResidential Water Supply(single) ft 170 rt in.
❑Industrial/Commercial ❑Residential Water Supply(shared) F z
❑Irri ation ❑Wells>100,000 GPD FROM TO `MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 3 ft. cement pour
❑Monitoring ❑Recovery 3 ft. 100 ft- bentonite tremmie
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD ^
❑Aquifer Test ❑StormwaterDrainage 100 ft' 180 rt• gravel 1#1 pour
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20 RII1tiT >e 'z4dtlitlonal="shuts g)cess8 1 ,'
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,Hardness,soil/rock type,grain size,etc.)
0 ft. 100 ft. clay ,. . :
4.Date Well(s)Completed: 1 0/26/21 Well ID# 100 ft- 135 ft- sand
5a.Well Location: 135 tt• 150 tt• clay /
Catherin Pierce 150 ft• 151 ft• limestone 021
Facility/Owner Name Facility ID#(ifapplicable) 151 ft' 180 ft- sand
56 Henry Jones Dr Whiteville NC 28472
Physical Address,City,and Zip ft. ft.
Columbus ��
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certi Ication ••J!/ 7
N W
6.Is(are)the well(s): I_IPermanent or ❑Temporary Signa ure ofCerti ied Well ntractor Date
By signing this form,I hereby certii ,that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or [!]No 15A NCAC 02C.0100 or ISA 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 oJ'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.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 180 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ijdierent(example-3@200'and 2@I00')
25 24a. For All Wells: Original form to Division of Water Resources (DWR),
Iff Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
water level is above casing,use"+"
11.Borehole diameter•' 6 (in.) 24b.For Injection Wells: Copy to.DWR,Underground Injection Control(IUC)
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
(gP ) Method of test: ~13a.Yield m 20 I r Permit Program,1611 MSC,Raleigh,NC 27699-1611 13b.Disinfection type: Granular Amount: 1/8
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018