GW1-2021-00501_Well Construction - GW1_20211222

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Hugo Rivas -
FROM TO DESCRIPTION
Well Contractor Name
3159
ft. ft.
NC Well Contractor Certification Number
1S�'><IT1;1U+�iisllly+s ar initl-case ,vrslls z�R`INi*,12 � cabte
Mcpherson Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft 195 ff 4 '" seh40 1pvc
ltli i?It`t'I1B7�If�'r: ' hetT®st=dosetll .��
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 SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 195 ft' 215 ft 4 '" 10 sch40 pvc
❑Geothermal(Heating/Cooling Supply) CJResidential Water Supply(single) ft. 195 ft 1"•
❑Industrial/Commercial ❑Residential Water Supply(shared) IS t _
❑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:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19}fiANA1GR :) P € sable x
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL r EMPLACEMENT METHOD
❑Aquifer Test ❑Storrnwater Drainage 100 ft• 215 ft• gravel#1 pour
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20 11i G1 ch_tdtiittoaal=alttets3(aec€a; Y .,,.
FROM TO DESCRIPTION(color,hardness,soNrock e, rain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
0 rt. 40 ft. sand
4.Date Well(s)Completed: 1 0/1 4'/21 Well ID# 40 ft• 120 ft• clay
5a.Well Location: 120 ff 135 ft• sand
Henry Spaulding 135 ft- 170 ft. clay 202?
Facility/Owner Name Facility lD#(if applicable) 170 It. 180 ft- sand/clay
3112 Old Northeast Rd Lake Waccamaw 28450 180 ft. 215 ft. sand
Physical Address,City,and Zip
ft. ft. I 1
Columbus _? _
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.CeRum
ation:
N W dAlu
6.Is(are)the well(s): nPermanent or ❑Temporary Signaturk of Certif dqk1cl(Tft#r0r 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 ONo 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a copy
If this Lr 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 an the back of this fmm.
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 ifnecessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 215 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdierent(example-3@200'and 2@100)
40 24a. For All Wells: Original form to Division of Water Resources (DWR),
f Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
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 DR,CCPCUA
13a.Yield m 70 Method of test: Air 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