GW1-2022-07031_Well Construction - GW1_20220726

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Hugo Rivas fff4.tWAR �
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
3159
ft. ft. ,
NC Well Contractor Certification Number 1 OIITER`CA iG forrt dlh-casediXells A_ R<IINER ff Itedble
Mcpherson Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 [t• 215 ft 2 '" sch40 pvc
Company Name
,1'6:'1NiYER?CASING.QR TUBING` eitbei teal"closed,loo - �- �'_
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Canty,State,Variance,etc) ft. [[. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: -`;!7•-SC1tEEN,_,, a .�>� . . ._<.'< ._�.'� .�>a = �"'��, _
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL `
❑Agricultural ❑MunicipabTublic 215 ft' 225 ft 2 in. 8 sch40 pvc
❑Geothermal(Heating/Cooling Supply) [!]Residential Water Supply(single) fir 215 ft in.
❑lndustriaUCommercial ❑Residential Water Supply(shared) 1&t=RQUTs3
. .. �: .._.. s
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 3 fc. cement pour
❑Monitoring ❑Recovery 3 ft. 100 ft. bentonite tremmie
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
49rSAND/GRlAVEli,l'ACK`if ilfi Ilcalile 3
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD~ '
❑Aquifer Test ❑StormwaterDrainage 100 ft. 225 ft' gravel#1 pour
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 320 pRII LINGLOG.attacti sddlHiitiallsheets if tiecessa -
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soi9rock type ram size,etc.)
0 rt. 15 ft. sand
4.Date Well(s)Completed: 5/1 7/22 Well ID# 15 ft. 110 ft. clay
5a.Well Location: 110 ft• 135 ft sand
Ambrosy Spaulding 135 ft• 180 ft• clay
Facility/Owner Name Facility ID#(if applicable) 180 ft' 205 ft• sand-clay
68 Spaulding Ln Clarkton NC 28433 205 ft• 225 ft• sand
Physical Address,City,and Zip
ft. ft.
jUL
27:RE1M"ARf{S,vrtt jt r`n
Columbus
County Parcel Identification No.(PIN) WAX800i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Ce 'f ation•
N W ,6 5/17/2022
6.Is(are)the well(s): ClPermanent or ❑Temporary Signature of C ified We ontractor Date
By signing thisform,]hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ItNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that 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.
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 I 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.SUBNHTTAL INSTRUCTIONS
9.Total well depth below land surface: 225 (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@100D
50 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"I,,Statie water level below top of casing: Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If
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: Rota'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
Permit Program,1611 MSC,Raleig)z,NC 27699-1611
13a.Yield(gp-) 30 Method of test: I r
13b.Disinfection type: Granulated Amount: 1/8 Ibs
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018