GW1-2021-00495_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
NC Well Contractor Certification Number -
1 �'U,T� ,StI�G fu�ltiu"ltlscased�tielts EJRT�I�R' - able`. � �:
Mcpherson Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name
0 ft 240 ft- 4 in. sch40 pvc
z
_1Yr;�l+7�E�.cI1!f .t311t $AN,Cs i .nta[`:�nsett�
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 v SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 240 ft• 260 ft- 4 in. 10 Jsch40 pvc
❑Geothermal(Heating/Cooling Supply) CJResidential Water Supply(single) ft 240 ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
131ni ation ❑Wel1S>100,000 GPD FROM TO ..F MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 3 et
❑Monitoring ❑Recovery 3 ft• 100 ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 100 f`' 260 ft• gravel#1 pour
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer0 RITdtIGI ateiitldiBo =setslfieea
a,
FROM TO DESCRIPTION(color,hardness,soil/rock e,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
0 ft. 10 ft. sand
4.Date Well(s)Completed: 1 1/26/21 Well ID# 10 ft• 145 ft' clay
5a.Well Location: 145 fL 160 f` sand
Landon Merritt 160 f` 220 ft• clay i
Facility/Owner Name Facility ID#(if applicable) 220 ft' 260 f`• sand
147 Antioch Church Rd Whiteville NC 28472 z 2 20
Physical Address,City,and Zip
Columbusx: �
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.Ce 'fieation:
N W ,f/1 4(/
6.Is(are)the well(s): nPermanent or ❑Temporary Si ature rtifie e Well ontractor Date
By signing thisform,I hereby certtfi,that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ItNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill aut 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 farm.
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:260 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@100')
60 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+" m Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
/J
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(gP m) 70 Method of test• Ai r Permit Program,1611 MSC,Raleigh,NC 27699-1611
'
13b.Disinfection type: granular Amount: 1/8
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018