GW1-2021-00492_Well Construction - GW1_20211222

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Hugo Rivas x4.. 1IR°zolvl _; _
Well Contractor Name FROM TO DESCRIPTION
ft. ft. ,
3159
ft. ft.
NC Well Contractor Certification Number
15 t3CITER;Czr►StNt�: drinulii=caae3�ve Is t?1z�IlV1i,R= table•�_ � .�;,., .'r
Mcpherson Well Drilling FROM 111TO DIAMETER THICKNESS MATERIAL
Company Name
0 ft- 1150 ft. 2 in sch40 pvc
_16:�1ViYE12=C�511Y�,+DRt�JB�t�y "e�Ihertoal�to�ed-loa _
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): tFROM
ft. in.
Water Supply Well: TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 60 f`' 2 in' 8 sch40 pvc
❑Geothermal(Heating/Cooling Supply) ClResidential Water Supply(single) 50 fL in.
❑Industrial/Commercial ❑Residential Water Supply(shared)❑Irri ation ❑Wells>100,000 GPD TO MATERIAL. R EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 f` 3 f` 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 METHODfi
❑Aquifer Test ❑StormwaterDrainage 100 f` 160 f` gravel#1 pour
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 2U: tiIttVI;LQ_1� att�tltaatldittonalaheetslf%ecisstiom
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soft/rack type rain size,etc.
0 ft- 110 f`- clay
4.Date Well(s)Completed: 1 1/1 9/21 Well ID# 110 f`. 120 f`' sand
5a.Well Location: 120 f`' 150 f`' clay
JimmyDew 150 f` 160 f` sand r
G,.
Facility/Owner Name Facility ID#(if applicable)
1474 Harrelsonville Rd Whiteville NC 28472 VEC 2 2 , T
Physical Address,City,and Zip
Columbus ;2I:ItE1G1ARKS, r..., aa3 r. " x:
County Parcel Identification No.(PIN) t
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Ce 'fieation: // 7
6.Is(are)the well(s): Permanent or ❑Temporary Signature ofitertified VI Contractor Date
by signing this form,I hereby certify 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 I5A NCAC 02C.0100 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 I 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: 160 (ft.)
For multiple wells list all depths ifdierent(example-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
30 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+"Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If
11.Borehole diameter: 6 (in) 24b.For Injection Wells: Copy to;DWR,Underground Injection Control (NC)
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
n)r Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 20 Method of test: „
13b.Disinfection type: granular Amount: 1/8
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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