GW1-2022-07028_Well Construction - GW1_20220726

WELL CONSTRUCTION RECORD GW-1 For Internal Use Only:
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1.Well Contractor Information:
Hugo Rivas T4eylilTEIt7A1+Ika .-f,. _ ,
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
3159
tit. ft.
NC Well Contractor Certification Number 15:OUTER EASING fur innlH 'if aMwlcable
McPherson Well Drilling FROM TO DIAMETER THICKNESS MATERIAL kfy
0 ft- 235 ft- 2 in. sch40 pvc
Company Name �„ } ;-
.15:VMRJGAS1NG 0R PCIBING'"eolheuma[cliised-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: 17,SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS - MATERIAL
❑Agricultural ❑Municipal/Public 235 1- 235 ft• 2 in' 8 1sch40 Jpvc
❑Geothermal(Heating/Cooling Supply) IlResidential Water Supply(single) ft- 235 ft in.
❑hidustrial/Commercial ❑Residential Water Supply(shared) IKGROTiT V T
❑hri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 3 et. cement pour
[]Monitoring ❑Recovery 3 ft- 100 ft. bentonite tremmie
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.,5(NU/GR#VEL PACI{ if a ica57e.
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 100 ft• 245 ft• gravel#1 pour
❑Experimental Technology ❑Subsidence Control ft. [t.
❑Geothermal(Closed Loop) ❑Tracer N20.;pRT1h11NG'I(G nttseb-additfdnal sLects ffaecessa 4
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soillrock type rain size,etc.)
0 ft' 80 ft. clay
4.Date Well(s)Completed: 5/23/22 Well ID# 80 ft. 95 ft. sand
5a.Well Location: 95 ft. 160 ft' clay MtUUVE
Joey McPherson 160 ft- 190 ft. sand
Facility/Owner Name Facility ID#(if applicable) 190 ft• 210 ft- clay
1315 Roseland Rd Chadbourn NC 28431 210 ft• 245 ft• sand k*CMOSon P*C u
Physical Address,City,and Zip DOG
Columbus zt.REifnRxs <_ k
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one fat/long is sufficient) 22. r'freation-
N W D 5/�32022
6.Is(are)the well(s): InPermanent or ❑Temporary ignature ACcrtified Well Contractor Date
By signing thisform,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or I!lNo 15A NCAC 02C.0100 or 15A NCAC 01C.0100 Well Construction Standards and that a copy
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 otiwter.
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: 245 (ft.)
For multiple wells list all depths if different(example-3@200'and 2@100) 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),
If
f water level is above casing,use"+"Static water level below top of casing: (ft.) 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)
p * Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: f�`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
(gP )
13a.Yield m 20 Method of test• p A I r Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Granulated Amount: 1/8 lbs
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-201 S