GW1--02023_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 applicable)
Mcpherson Well Drilling FRONT TO DIAMETER THICKNESS MATERIAL
0 ft- 150 ft 2 i 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•
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 150 ft- 160 ft 2 i"' 8 sch40 pvc
0 Geothermal(Heating/Cooling Supply) ClResidential Water Supply(single) ft 150 ft '"'
❑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)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 100 ft' 160 ft- gravel#1 • pour
❑Experimental Technology OSubsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geotheal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,baroness soil/rock type grata size ere)
rm
0 ft- 40 ft- sand
4.Date Well(s)Completed:2/11/24 Well ID# 40 ft- 140 ft- Clay
5a.Well Location: 140 ft- 160 ft- sand •t; ,;.L'L; ;' ';;r�a j )
Edna Carter ft.
ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft. i P!?" 0 1 20244
372 Carter Circle Dr White Oak 28399 ft. ft.
IDOG
Physical Address,City,and Zip ft. ft. j j{j�C
Bladen 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.Certif ation
N W ii� 2/11/2024
6.Is(are)the well(s): C)Permanent or ❑Temporary
Si ature of rtified lVIR l�tractor Date
By signing this form.Thereby certifj'that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or IlNo 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 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: 60 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple we/Is list all depths ifdii different(erample-3@200'and 2@100)
10.Static water level below top of casing:40 (ft.) 24a. For All Wells: Original form,to Division of Water Resources (DWR),
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: I 24d.For Water Wells producing er 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm)20 Method of test:Air Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Granulated Amount: 1/8 lbs
t