GW1-2022-01334_Well Construction - GW1_20220124

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.
I
NC Well Contractor Certification Number }3;QUTER CsA$.1NG'for'mti -cased tivElls'40R;I3I+IER,ff` lieaDle
Mcpherson Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft• 158 ft 2 in sch40 pvc
�6i.1NZVER�SINTD t?R'�NB�iG`, ehtlterrdisfr'iused-too <= _.}. `:
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.1 111 SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 158 1" 168 1- 2 in. 8 sch40 pvc
❑Geothermal(Heating/Cooling Supply) CJResidential Water Supply(single) ft- 158 ft- in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑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
9"S3,IV/ i2Al�l�_1'ACK`P 'fc8tilc
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD v,
❑Aquifer Test ❑StormwaterDrainage 100 ft• 168 ft Gravel#1 pour
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 2Rp1ZII ]fi1G7sQG att3eti-aktfdthonhl'she€tX-,4i ci i
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,gmin size,etc.)
0 ft. 5 ft. sand
4.Date Well(s)Completed: 1 2/22/2 Well ID# 5 ft' 45 ft' clay
5a.Well Location: 45 ft' 70 ft sand-clay
Gwen Schmehl 70 ft• 71 ft• limestone
Facility/Owner Name Facility ID#(if applicable) 71 ft. 85 ft. sand
898 Livingston Chapel Rd Delco NC 28436 85 ft• 120 ft• clay
Physical Address,City,and Zip 120 ft- 135 ft' sand
Columbus
County Parcel Identification No.(PIN) 135-136 Limestone 136-145 clay 145-168 sand
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certi tcation:
N W 12/22/2021
6.Is(are)the well(s): I'Permanent or ❑Temporary Si azure of ified Contractor ;;v• \"I;Date
By signing this form,I hereby certify that the we/1(s)was(we r)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or InNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 We/!Cons t 1,.tn4trfl�"b 'hal 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. z ��UU LL��
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details: .
You may use the back of this page to provide additional well construction info
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same t .
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may a'Iso�ittaeh'additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 168 (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')
4 0 24a. For All Wells: Original form to Division of Water Resources (DWR),
if Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
/Jwa[er level is above casing,use'"+'"
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: 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