GW1--04745_Well Construction - GW1_20240812

Print Form 1
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
LLOYD MARES 14.WATERZONES
FROM TO • DESCRIPTION
Well Contractor Name
ft. ft.
2547-A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
REGISTERWELL COMPANY FROM TO DIAMETER THICKNESS MATERIAL
ft. 240 ft. 2 in. .40 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.U/C,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 0 Munic ipal/Public 240 ft• 260 ft. in' .016 PVC
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. HOLE PLUG POUR
Monitoring LL( ecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge ❑(,roundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery D Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage 235 ft. 260 ft• #2 POUR
Experimental Technology D Subsidence Control ft. ft.
Geothermal(Closed Loop) []Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color.hardness,soil/rock IN pc.grain size.etc.)
Geothermal(Heating/Cooling Return I "]Other(explain under#21 Remarks) 0 ft. 6 f[. SAND
4.Date Well(s)Completed:07/09/24 Well ID# 6 ft• 56 ft' SAND AND CLAY LAYERS
5a.Well Location: 56 ft. 75 It. CLAY_
HENRY SMITH 75 ft• 85 ft• SAND AND CLAY LAYERS
Facility/Owner Name Facility ID#(if applicable) 85 It• 97 ft. CLAY
398 HALLS POND RD ROSE HILL NC 28458 97 ft. 115 ft• SAND AND CLAY LAYERS
Physical Address,City,and Zip 115 It. 122 ft. C LAY
DUPLIN 21.REMARKS •
County Parcel Identification No.(PIN) - 1 1 f(,)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: A U(� G 2UC 4
(if well field,one lat/long is sufficient) 22.Certification:
34.839948 -78.152296 . d'.:•t, A-r,c,br, '
/ 7 A DWCdc-07/22124
6.Is(are)the well(s)0Permanent or Temporary Signature of a,�'fied Well Contractor Date
By signing this form,/hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: °Yes or 13 No with 15A NCAC 02C.0100 or 1SA 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 I 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: 240 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if diferent(example-3@200'and 1@100) construction to the following:
10.Static water level below top of casing:64 (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: 3 7/8" (in.) 24b.F9r Injection 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) 25 Method of test:AIR 24c. For Water Supply& Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
I3b.Disinfection type: HTH Amount: 8 OZ completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

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