GW1-2021-00498_Well Construction - GW1_20211222

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Hugo Rivas T4:WA11 R'�ON
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
3159
ft. ft.
NC Well Contractor Certification Number
1S:S11F1'ER_C�15TT�7G araiulh-caked;"" )s;OR.1�11±TF�lt tt''� bte�- � _.
Mcpherson Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft 167 ft. 2 in. sch40 pvc
Company Name
I6'11v11t��A51N�OReTIl�iG:; e3tlieamal elo�ed�oo ,:
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: 37a S4AF
FROM I TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 167 ft• 177 ft- 2 in. 8 sch40 pvc
❑Geothermal(Heating/Cooling Supply) InResidential Water Supply(single) ft- 167 it• in.
❑industrial/Commercial ❑Residential Water Supply(shared) CIS_Opo
❑hri 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:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19:SANDI.G i3AC1K"iI c"rtlilh }`-
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 100 it' 177 it• gravel#1 pour
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 2Q:pRILEINGTOG.attse6additiooa7sha}etsifpe lift , T
FROM TO DESCRIPTION(color,hardness,soll/mck s type, rain size,etc.) x
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
0 rt. 35 ft. sand
4.Date Well(s)Completed: 1 O/5/21 well ID# 35 t'• 70 t'' clay
Sa.Well Location: 70 ft. 71 ft. limestone
Lorris Dale 71 it• 95 it• clay
Facility/Owner Name Facility iD#(if applicable) 95 it• 105 t' sand UIC22
2673 Livingston Chapel Rd Delco NC 28436 105 it• 140 it• clay
Physical Address,City,and Zip 140 it• 150 it• sand
Columbus " z -
County Parcel Identification No.(PIN) 150-151 Limestone 151-177 sand
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certifica'on: 9 p� ''1//
N W
6.Is(are)the well(s): ❑Permanent or ❑Temporary Signature of Certifi d Well?Cont&tor 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 [INo 15A NCAC 02C.0100 or I SA NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information and explain the nature ofthe ofthis 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-I 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: 177 (ft.)
For multiple wells list all depths ifdt fferent(example-3@200'and 2 a!00') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 35 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level it shove casing,use"+"
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
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: RO}`ar 1��
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) Method of test: Ai r
Permit Program,1611 MSC,Raleigh,NC 27699-1 61 1
13b.Disinfection type: Granular Amount: 1/8
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018