GW1--04972_Well Construction - GW1_20240816

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• WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
V
'I.Well Contractor Information:
LLOYD MARES 14.WATER ZONES
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 CO.INC FROM TO DIAMETER THICKNESS MATERIAL
0 ft- 70 ft. 4 'n' .40 PVC
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#:N/A FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.(B',County,State,Variance,etc.) fL ft. in.
3.Well Use(check well use): ft ft. in.
17.SCREEN
Water Supply Well:
FROM _ TO DIAMETER SLOT SIZE THICKNESS MATERIAL
©Agricultural 10Municipal/Public 70 ft. 90 ft. 4 in' .016 PVC
Geothermal(Heating/Cooling Supply) 0 Residential Water Supply(single) 90 ft. 95 ft. 4 rn' .016PVC
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 0 ft. HOLE PLUG POUR
Monitoring Recovery ft. R.
Injection Well:
ft. ft.
Aquifer Recharge QGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery [�Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ❑Stormwater Drainage 68 ft• 115 ft- GRAVEL#2 POUR
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRI I.1.ING LOG(attach additional sheets if necessary)
rRU�I 'I'O DESCRIPTION(color,hardness.soil/rock type,train size,etc.)
Geothermal(Heating/Cooling Return) []Other(explain under#21 Remarks) 0 ft' 16 - SAND(COURSE)
.1.Date Well(s)Completed:7/2/24 Well ID# 16 ft. 25 ft• SAND AND CLAY 1
5a.Well Location:
25 ft. 36 ft' CLAY
BOB IVEY 36 ft. 49 ft. SAND(COURSE)
Facility/Owner dame Facility ID#(if applicable) 49 ft• 70 ft• CLAY WITH SMALL SAND STRIPS
TOM HERRING RD GOLDSBORO NC 70 f' 90 ft. SAND(MEDIUM COURSE)
Physical Address,City,and Zip 90 ft. 95 ft• CLAY 1
WAYNE 21.REMARKS • ._
County Parcel Identification No.(PIN) AUL 1 16?4
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: k
(if well field,one lat/long is sufficient) 22.Certification: - '• . D-i‘t,.._,::,
35.332804 N -77.962732 W / / 7 �
08/10/24
6.ls(are)the well(s)JPermanent or D'femporar� Signature of fled We1lContractor 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: D 1'es or x❑No with ISA 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: 115 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifl@rent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing:28 (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 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) 50+ Method of test:AIR 24c. For Water Sunnly& Iniection 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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