GW1-2022-07034_Well Construction - GW1_20220726

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Hugo Rivas r4WA1ERwNls _�. A
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
3159
ft. ft
NC Well Contractor Certification Number I5:0[YPER CA6ING.for:mulfl-eased,Yells`.OIttINER't!''a licalile
Mcpherson Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name
0 ft- 205 ft. 4 in. sch40 pvc
ilt:INNEWCASINfrt7RTUBING' ed liedmalclosed
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 .. x «, _ c.
FROM I TO DIAMETER SLOT SIZE THICKNESS ~ MATERIAL
❑Agricultural ❑Municipal/Public 205 It' 225 ft 4 in' 10 Sch40 pvc
❑Geothermal(Heating/Cooling Supply) CJResidential Water Supply(single) fr• 205 fr-
❑lndustrial/Commercial ❑Residential Water Supply(shared) fg;GRO.1F)* ,
❑hri ation ❑Wells>100,000 GPD FROM TO MATERIAL o-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
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 100 IL 225 Ir• gravel#1 pour
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer 2ti ibRILI INGIi()G nttaehaddihoti3d'3Tteets Ifnebessa s <,:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.
0 ft. 18 ft. sand
4.Date Well(s)Completed: 6/21/22 Well ID# 18 ft• 55 It sand/clay
5a.Well Location: 55 It. 130 II• clay
Kirk Douglas 1300 Ir• 150 Ir• sand
Facility/Owner Name Facility ID#(if applicable) ft 170 ft- clay r)
674 Pat's Rd Orrum NC 28369 ft- 190 Ir• sand
Physical Address,City,and Zip ft- 200 ft. clay
Robeson £MAItKS
County Parcel Identification No.(PIN) 200-225 sand D%,,Q/3
00 no
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: +7 9
N W
6.Is(are)the well(s): ClPermanent or ❑Temporary igna a of rtificd We ontractor 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 MNo 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 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: 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@I00)
10.Static water level below top of casing: 50 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+"
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
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 DWR,CCPCUA
13a.Yield(gpm) Method of test: Al
Perm Program,1611 MSC,Raleigh,NC 27699-1611
r l.,
Permit—Program,
13b.Disinfection type: Granulated Amount: 1/8 lbs
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018