GW1-2022-07026_Well Construction - GW1_20220726

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Hugo Rivas .r4:vvATEIiZONES
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
3159
ft. ft.
NC Well Contractor Certification Number IS:OUTER CASING ot'nialti eak0r6lIs;UR=]LINFl2 tf•:a' hca6le"- t
Mcpherson Well Drilling FROM TO DIAMETER THICIQVESS MATERIAL
Company Name 0 ft. 170 ft- 2 t" sch40 pvc
K--INNEWCASING_OR TIISING` 'eiif4e'r"m91`dosed 10 " " "'"
ti a,
2.Well Construction Permit#' FROM TO DIAMETER THICKNESS l 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: 4"CREEN .
FROM I TO DIAMETER SLOT SIZE I THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public 170 f' 180 ft. 2 "' 8 Isch40 1pVc
❑Geothermal(Heating/Cooling Supply) [!]Residential Water Supply(single) ft. 170 ft. in
❑lndustiial/Commercial ❑Residential Water Supply(shared) .I8:GROUT u..< �..F , .
❑TILL ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT~
Non-Water Supply Well: 0 ft' 3 it. Cement pour
❑Monitoring ❑Recovery 3 ft. 100 ft. bentonite tremmie
Injection Well: . ft. ft.
❑Aquifer Recharge []Groundwater Remediation
_19:SAND/.GRAV, :
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 100 ft' 180 et. gravel#1 1pour
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.'pltTliL1PIGTsfIG attactiaddihonial's9ieetsifiiecessu _
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soillrock type,Yaraln size,etc.
fl
rt. 35 rt• sand
4.Date Well(s)Completed: 5/21?2�22 Well ID# rt 110 rt clay
5a.Well Location: ft. 135 ft. sand ,
Jerome Rooks/Bryan Scott it. 150 «• clay 111L ;
202�—
Facility/Owner Name Facility ID#(if applicable) ft. 180 rt• sand
260 Angelas CT Whiteville NC 28472 ft. ft. procao S,n9 U •
Physical Address,City,and Zip ft. ft.
Columbus zs:RE1ViARKS _ _
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one latllong is sufficient) 22.C tit' ation
N W
6.Is(are)the well(s): L9Permanent or ❑Temporary SIKgriaturc of C,AifiW Wei l ontractor Date
By signing this form,I hereby certi,that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or LhNo 15A NCAC 01C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a cop),
If this is a repair,fill out known well construction information and explain the nature ofthe 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 1 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: 180 (ft-)
For multiple wells list all depths if different(example-3@200'and 2@I00) Submit this GW-1 within 30 days of well completion per the following:
50 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ijwater level is above casing,use"+"
f Static water level below top of casing: (rt) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
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: AI r
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Granulated Amount: 1/8 IbS
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018