GW1--02016_Well Construction - GW1_20240401

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.Well Contractor Information:
Hugo Rivas 14.WATER ZONES
FROM TO DESCRIPTION;
Well Contractor Name
ft. ft.
3159 ft. ft.
• NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Mcpherson Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 138 ft- 4 in' sch40 pvc
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
Z.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.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public 138 ft- 158 ft- 4 , 12 sch40 pvc
❑Geothermal(Heating/Cooling Supply) L9Residential Water Supply(single) R• 138 it in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 3 ft- cement pour
OMonitoring ❑Recovery 3 ft. 100 ft- bentonite tremmie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
['Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL ' EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 100 ft. 158 ft- gravel#1; pour
['Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ['Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type groin size etc.)
0 ft' 50 ft- clay _
4.Date Well(s)Completed: 3/4/24 Well ID# 50 ft- 65 ft- sand ( " _•! ^7)
5a.Well Location: 65 ft- 120 ft- clay
Calvin Callahan 120 ft' 122 ft. limestone PR o f 20[4
Facility/Owner Name Facility ID#(if applicable) 122 ft- 130 ft- clay 1 tn57:Tr.: :, '3.--,-!,,:.:.;;)�N
895 Loop Rd Bolton NC 28423 130 ft- 140 ft- sand DV.:tom 3')G
Physical Address,City,and Zip 140 ft- 142 ft- limestone
Columbus 21.REMARKS
County Parcel Identification No.(PIN) 142-150 sand 150-151 limestone 151-158 sand
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Cer t,[cation:
N W / 0 A 3/4/2024
6.Is(are)the well(s): OPermanent or OTemporary Si state ofC: ified We ontractor Date��
By signing thisfornt I hereby certify that the,well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or l No ISA NCAC 02C.0100 or ISA 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 remark 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-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: 158 (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'
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 50 (fL) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter 8 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(TUC)
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)50 Method of test:Air
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Granulated Amount: 1/8 lbs