GW1--02018_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* 200 ft- 2 in' sch40 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,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 200 ft- 210 ft- 2 in. 8 sch40 pvc
❑Geothermal(Heating/Cooling Supply) inResidential Water Supply(single) ft' 200 ft- in,
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000GPD 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)
❑Aquifer Storage and Recovery ❑Salinity Hamer FROM TO MATERIAL' EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 100 ft' 210 ft- gravel#1 pour
❑Experimental Technology OSubsidence Control ft. ft. I
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,soil/rock type grain size,etc.)
2/8/24 0 ft' 15 ft• sand-clay
4.Date Well(s)Completed: Well EN 15 ft- 85 ft' clay
5a.Well Location: 85 ft' 110 ft- sand
Tommy Reaves 110 ft- 145 ft, limestone every other foot
Facility/Owner Name Facility ID#(if applicable) 145 ft- 170 ft- sand (`^ '^ „
413 Church St Lake Waccamaw NC 28450 170 ft. 180 fL clay 'L Le i Y' `V`
Physical Address,City,and Zip 180 ft. 210 ft- sand A' L �
Columbus 21.REMARKS /
4
County Parcel Identification No.(PIN) Inks. ' •'^ -7.
.-
:P.r•a:Y.� i 1Ra
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: V'r `�(�
(if well field,one 1at/long is sufficient) 22.Cer lcation• r
N W / ,0G ,-- 2/8/2024
6.Is(are)the well(s): Permanent or OTemporary Signature of ertified Well Contractor 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 i9No 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 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:210 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdt_(jerent(example-3@200'and 2@100)
,t
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing:40 (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter 8 (in.) 24b.For Iniection Wells:Copy to DWR,Underground Injection Control(1UC)
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
Permit Program,1611 MSC,Raleigh;NC 27699-1611
13a.Yield(gpm)20 Method of test:Air
13b.Disinfection type: Granulated Amount: 1/8 lbs