GW1--02019_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
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. 168 ft- 2 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
DAgricultural ❑Municipal/Public 168 ft- 178 It. 2 in. 8 sch40 pvc
0 Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft- 168 ft- in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
El Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft, 3 ft. cement pour
❑Monitoring ❑Recovery 3 it. 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. 178 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) DOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soi0raek type grain size,etc.)
0 ft. 30 ft- sand-clay
4.Date Well(s)Completed:2/7/24 Well ID# 30 fL 55 ft- sand
5a.Well Location: 55 ft. 100 ft. clay . E R...a*ir..y i 7 j ..1
Gloria Mitchell 100 ft. 135 ft- sand
135 ft- 150 ft' clayAPR 0 r 2G24
Facility/Owner Name Facility 1D#(if applicable)
3090 Pocosin Rd Lake Waccamaw NC 28450 150 ft. 178 ft' sand ' In&c;,..-?.?a :17..,rt,,f„_ ;�>I 3 i)
Physical Address,City,and Zip ft. ft. G l�v(;; 0-(
Columbus 21.REMARKS
• 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.Cer,f ation:
N W r e' Gc....-------- 2/7/2024
6.Is(are)the well(s): nPermanent or ❑Temporary Siuiaturc of C ified Well ctor Date
By signing this form,I hereby cert#1'that the well(s)was(were)constructed in accordance wills
7.Is this a repair to an existing well: • ❑Yes or l No i5A 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
1
9.Total well depth below land surface: 78 (ft.) Submit this GW-1 within 30 days oftwell 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 (ft.) 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(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 over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:Air
20 Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Granulated Amount: 1/8 lbs