GW1--02017_Well Construction - GW1_20240401

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Hugo Rivas 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION '
3159 ft. ft.
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. 238 ft. 2 in• sch40 pvc
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit it: 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
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agriculmml OMunicipal/Public 238 it. 248 ft- 2 in- 8 sch40 pvc
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft• 238 It. in.
0 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
❑Monitoring ❑Recovery ,_ 3 ft• 100 ft- bentonite tremmie
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
DAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 100 ft. 248 ft• gravel#1 pour
❑Experimental Technology ❑Subsidence Control ft. ft.
OGeothermal(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,soiVrock type,grain size,etc.)
0 ft- 50 ft- sand
4.Date Well(s)Completed:2/21/24 Well m# 50 ft- 65 ft- sand
Sa.Well Location: 65 ft' 140 t` clay " ',K ..,
Mary Dean 140 ft• 141 ft• limestone • i `- lf.
°'' ..:.r,V '.:ft
)
Facility/Owner Name Facility ID#(if applicable) 141 f1. 150 ft- sand ,' 4 PP .) 1 2021
876 Avery Ward Rd Nakina NC 28455 150 ft- 151 fL limestone' -
Physical Address,City,and Zip 151 ft. 230 ft. clay trl,..iira:'1n ,-'! W,-r'linl
Columbus 21.REMARKS " N���=
County Parcel Identification No.(PIN) 230-248 sand
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Cer ifi lion: it,
•
N W , ,� 9 �//^� 2/21/2024
6.Is(are)the well(s): InPermanent or ❑Temporary Signature of CertSfied Well C ctor Date
By signing thisform,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo ISA 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:248 (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@100')
40 I
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.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
11.Borehole diameter: 8 (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 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 ove 1100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:Air
30 Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Granulated Amount: 1/8 lbs