GW1--04633_Well Construction - GW1_20240809

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e WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
LLOYD MARES 14.WATER ZONES I
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
2547-A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
REGISTERWELL CO INC FROM TO DIAMETER THICKNESS I MATERIAL
0 ft• 163 ft• 4 in. .4 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 0Municipal/Public 163 ft 183 ft. 4 in' .16 PVC
Geothermal(Heating/Cooling Supply) E2 Residential Water Supply(single) ft, ft. in.
Industrial/Commercial 0 Residential Water Supply(shared)
18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft HOLE PLUG POUR
Monitoring ()Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge ()Groundwater Remediation Iq SAND/GRAVEL PACK(dapplicable)
Aquifer Storage and Recovery ()Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ()Stormwater Drainage 160 ft 183 ft #2 POUR
Experimental Technology 0 Subsidence Control ft. rt.
Geothermal(Closed Loop) 0 Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIP7 ION(color.hardness.soiUrock type,grain size,etc.)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) 0 ft. 7 ft. CLAY
4.Date Well(s)Completed:4/26/24 Well ID# 7 ft. 18 ft' SAND & CLAY _
5a.Well Location: 18 ft* 36 ft' SAND
FUTURE HOMES 36 ft• 57 ft• SAND& CLAY
Facility/Owner Name Facility ID#(if applicable) 57 ft• 59 ft• CLAY - ' 'a
'811 BOSTIC RD, ATKINSON NC 28421 "�'�` ' '�� -
59 ft• 61 ft' ROCK18"SOFT �'"�
Physical Address,City,and Zip 61 ft 105 ft. CLAY I I(; ,) 9 -)fl 21
PENDER 21.REMARKS
'County Parcel Identification No.(PIN) - C. ., 11.,.....-.
/i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one'at/long is sufficient) 22.Certification:
34.525156 �, -78.150434 W I/40VP 74/1.4/ 5/15/24
6.Is(are)the w ell(s)9Permanent or ()Temporary Signature of Sed Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ()Yes or ©No with]SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy 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 site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 183 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@I00) Construction to the following:
10.Static water level below top of casing:45 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing use'•+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6-3/4 (in,) 24b.For Infection Wells: In addition to sending the form to the address in 24a
ROTARY above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 50 _ __ Method of test:AIR 24c.For Water SUDDIV& Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: 6 OZ completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

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CUSTOMER: ADDRESS: S
THICKNESS FORMATION THICKNESS FORMATION
FROM TO (CLAY, SAND,ROCK, ETC.) FROM TO (CLAY, SAND,ROCK, ETC.)
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