GW1--08020_Well Construction - GW1_20231214

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
LLOYD MARES 14.WATER ZONES. .
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
2547-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
REGISTER WELL CO., INC FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 184 ft. 4 c tn. .40 PVC
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM • TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Stale,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
DAgricultural ❑MunicipaUPublic 184 ft' 204 ft. 4 in* .016 PVC
❑Geothermal(Heating/Cooling Supply) iJResidential Water Supply(single) ft. '184 ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Simply Well: - 0 ft' 20 ft' HOLE PLUG POUR
❑Monitoring ❑Recovery ft. ft.
Injection Well: -
ft. ft.
0 Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Sal inity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 180 ft* 204 ft- #2 POUR
❑Experimental Technology OSubsidence Control ft. ft.
❑Geothermal(Closed Loop) El Tracer 20.DRILLING LOG(attach additional sheets if necessary) _
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 8 ft. SAND _
4.Date Well(s)Completed: 10-18-23 Well ID# 8 ft• 42 rt. SAND&CLAY
ft. ft. `._
5a.Well Location: 42 45SHELL •4,,.•L';: c�* "^ 1
' JON CARNE 45 ft. 82 ft. SAND
DEC 1f202-1
' Facility/Owner Name Facility ID#(if applicable) 82 ft. 95 ft. CLAY •
PERLIE WATKINS RD, BURGAW, NC 28425 95 ft. 155 ft. SAND(MED/FINE) In'3r ,J?z.f?r:�:::r,•
Physical Address,City,and Zip 155 ft. 168 ft. CLAY Lvvk.,:,-00.
P E N D E R 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lot/long is sufficient) 22.Certification:
34.563101 N -77.853071 W L2-0 /A Ne 11/2/2023
6.Is(are)the well(s): ❑Permanent or ❑Temporary Signature ofCertifiey1ell Contractor Date
-- -- _ - -- -- -- -.- Bysigning this form,1-hereby cert fy thatthe.well(s)was:(were)constructed-in accordance-with- -
7.Is this a repair to an existing well: ❑Yes or CINo 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 1121 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: 204 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3 a 00'and 2@100')
13 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 0') Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use••+"
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24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: 6-3/4 (in.)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: ROTARY
24c.For Water Supply and Open4Loop 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) 15 Method of test: AIR
Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
13b.Disinfection type: HTH Amount: 80Z
'Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018

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