GW1-2022-09521_Well Construction - GW1_20221017

'I
I'
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: !'
1.Well Contractor Information:
Hugo Rivas 14.WATER ZONES F•_
FROM TO DESCRIPTION I
Well Contractor Name
3159 ft. r+. � I
n. ft.
NC Well Contractor Certification Number 15.OUTER CASING(forwels able
EER ORN
Mcpherson Well Drilling FROM MAT4RU1.
Con4myName 0 ft 230 rt 2 in JsCh40 Jpvc
16.INNER CASING OR TUBING eoth'ermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER T1DCXNESs I MATERIAL
List all applicable Nell construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft.
3.Well Use(check well use): tt. rL in
Water Supply Well: FROM REE TO DIAMETER SLOT SIZE TMCV24M MATERIAL
❑Agricultural ❑Municipal/Public 230 f`• 240 fL 2 in. 8 sch40 pvc
❑Geothermal(Heating/Cooling Supply) ClResidential Water Supply(single) fr. 230 f6 in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑rri ation ❑Wells>100,000 GPD FROM I TO MATERIAL! EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 f6 3 fL cement pour
❑Monitoring []Recovery 3 ft- 100 ft. bentonite tremmie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.`SAND/GRAVEL PACK a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 100 fL 240 IL gravel#1, pour
❑Experimental Technology ❑Subsidence Control n• ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothetmal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(mlor,hardness,soW-ck We ins etc
0 fA 35 fL sand-clay
4.Date Well(s)Completed:9/1 1/22 We11 ID# 35 fL 90 fL clay
5a.Well Location: 90 it. 110 IL sand
Michell Powell 110 R6 185 IL clay -.d EST'
�� l��' 4`
Facility/Owner Name Facility ID#(if applicable) 185 f`' 190 IL sand tC
3149 Blackwell Rd Cerro Gordo NC 28430 190 ft- 210 It- clay
Physical Address,City,and Zip 210 fL 240 fl- sand
Columbus
21.REMARKS t�" f :;`:1 := f➢'rt
A,%; r CG
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certlfica•on:
N W JYVfg GIAI� 9/11/2022
6.Is(are)the well(s): ClPermanent or ❑Temporary Si of Certified tich Contractor Date
By signing this form,I hereby certify that the I*ll(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 15A NCAC 02C,0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out!Drown well construction information and explain the nature of the ofthis record has been provided to the well owner.
repair under#21 remads section or on the back of thisform.
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 Ovee in Remarks Box).You may also attach additional pages if necessary".
drilled. 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:240 (ft) Submit this GW-1 within 30 days of rvet)completion per the following:
For multiple wells list all depths ifdifjerent(example-3@200'and 2@100) I
50 24a. For All Wells: Original form�to 1 Division of Water Resources (DWR),
if Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing use I I
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 Su 1 and O en-Loo !Geothermal Return Wells:Copy to the
(Le.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 Wm)30 Method of test: (r
Permit Program,1611 MSC,Raleigh,NC 27699-1611
i
13b.Disinfection type:Granulated Amount: 1/8 Ibs