GW1-2021-00494_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 l S K1U1ER't.AAANG tj�tiiu7d-eased iuel)s tf)R[s1NER; cable
Mcpherson Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft- 150 ft- 2 i" sch40 pvc
6.'.'11�iNR. SA!? i1RAV(s', fil6etialclosed�loo .`Y' . I IN
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Couni),,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): fL fL in.
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESSMATERIAL
❑Agricultural ❑Municipal/Public 150 f` 160 ft- 2 in-' 8 sch40 pvc
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft- 150 ff in.
❑Industrial/Commercial ❑Residential Water Supply(shared) r
`Y OUT
❑lni ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 3 [t. cement pour
❑Monitoring ❑Recovery 3 it. 100 ft- bentonite tremmie
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
?)19.,5'`, IRA'ir1T'AY 'I a collie W"' s.
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD '
❑Aquifer Test ❑StormwaterDrainage 100 f` 160 f` gravel#1 pour
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer :1A:pX2iTiL11�fG (2G affaahidltlonal3h�etsiffiecssa -a .:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,=rain size,etc.
0 ft- 100 ft- clay
4.Date Well(s)Completed: 1 0/29/21 Well ID# 100 f`• 110 ff sand
5a.Well Location: 110 f` 145 f`' clay
Carmen Banica 145 ft• 160 ft• sand 2
Facility/Owner Name Facility ID#(if applicable)
rt. ft.
330 N Miller St Chadbourn NC 28431 ft. fL
Physical Address,City,and Zip ft. ft. y s":'Jli`,' lJidll
Columbus z�.REMnRxs _
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Cer'tieation:
N W
6.Is(are)the well(s): InPermanent or ❑Temporary Si ature of ertified Tell C tractor Date
By signing this form,I hereby cert ,that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or IJNo 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 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 if different(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 forth to Division of Water Resources (DWR),
If water level is above casing,use"+" m Static water level below top of casing: VW 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(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
13a.Yield(gpm) 20 Method of test: Air
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