GW1--02024_Well Construction - GW1_20240401

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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. 148 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.
Water Supply Well: 17.SCREEN
. FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 148 ft. 158 ft. 2 in' 8 sch40 pvc
El Geothermal(Heating/Cooling Supply) C1Residential Water Supply(single) ft. 148 ft• in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
ID 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 0 Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
DAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 100 ft' 158 ft. gravel#1 pour
DExperimental Technology ❑Subsidence Control ft. ft. ,
OGeothermal(Closed Loop) OTracer 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,Brain size,etc.)
0 ft. 45 ft- sand
4.Date Well(s)Completed: 3/5/24 Well ID# 45 ft 60 ft. clay ' ' C";: '-' - 'lief
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5a.Well Location: 60 ft. 158 ft• sand a t L.A r L.. i 1�-�Ltt
Elwin Hernandez fL ft. t1PR 1 1 21374
Facility/Owner Name Facility ID#(if applicable) ft. ft.
361 Community Rd White Oak NC 28399 ft. ft. : lni;:irfi2;.4Zn Pr7:.5:-;•741 UX.X
Physical Address,City,and Zip
ft. ft. w t
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.Certi(cation: .-
N W w�dil 3/5/2024
6.Is(are)the well(s): lPermanent or OTemporary
Signature of C ied Well C tractor Date
By signing this form,Ilzereby certifr that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 1MNo 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 '
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9.Total well depth below land surface: 58 (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)
20 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"+"
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 r( 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm)20 Method of test:Air
Permit Program,1611 MSC,Raleigh,NC 27699-1611
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13b.Disinfection type: Granulated Amount: 1/8 lbs
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