GW1--04823_Well Construction - GW1_20240814

Print Form f
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 Numberr 15.OUTER CASING(for multi-cased wells)OR LINER(if apelicable)
REGISTERWELL CO., INC. FROM TO DIAMETER THICKNESS I MATERIAL
0 ft. 208 ft. 4 in. .4 [VC
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.IU( ( ot,,,n.State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
111
ater Supply Well: FROM 17.SCREENTO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ®Municipal/Public 208 ft. 223 ft. 4 in- .016 PVC
Geothermal(Heating/Cooling Supply) El Residential Water Supply(single) ft. f. in.
Industrial/Commercial ID Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
on-Water Supply Well: 0 ft. 20 ft• HOLE PLUG POUR
Monitoring Recovery ft. ft.
jection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery El Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0 Stormwater Drainage 225 ft 203 ft #2 GRAVEL POUR
Experimental Technology ESubsidence Control ft. ft.
Geothermal(Closed Loop) ID Tracer 20.DRILLING LOG(attach additional sheets if necessary)
ze
Geothermal(Heating/Cooling Return I ['Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soil/rock type,Brain 5 ,etc.)
0 ft• 35 ft• SAND
4.Date Well(s)Completed:5- 0 24 Well ID# 35 ft• 40 ft' CLAY
5a.Well Location: 40 ft• 55 f` SHELL&CLAY jT .-_-.. :•
CHERRY CONSTRUCTION 55 ft• 70 ft• CLAY IL•• , i! 1�
Facility/Owner Name Facility ID//(if applicable) 70 ft. 81 ft. SAND(MED) AUG 1 4 2021
3604 ASHFORD PLACE, GREENVILLE, NC 27858 81 ft. 95 ft. ROCK&SAND
ir.fa:,a,: •-r •
Physical Address,City,and Zip 95 ft• 101 ft SAND&CLAY *7'`4- .J t
PITT 21.RI.MARKS
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.Certification:
35.561759 N -77.380966 W 2--LC 74/0.. '3'
5/30/2024
6.Is(are)the well(s)Ox Permanent or D'I'e[up()rar Signature of C Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: El lies or Q No with 15A NCAC 02C.0100 or 15A 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:
S.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-I 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: 223 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths fdifferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing:42 (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)25 Method of test:AIR 24c. For Water Supply&Infection 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-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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