GW1--04983_Well Construction - GW1_20240828

IPrint Form
• WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.1Nell Contractor Information:
LLOYD MARES 14.WATER ZONES
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 ap licable)
REGISTERWELL CO., INC FROM TO DIAMETER THICKNESS MATERIAL
0 ft• 226 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.U1C,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 QMunicipal/Public 226 ft. 246 ft• 2 in' .016 PVC
Geothermal(Heating/Cooling Supply) x0Residential Water Supply(single) ft. ft. in.
Industrial/Commercial 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 0 Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge OGroundwater Remediation --.1
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Q Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [ StormwaterDrainage 225 ft. 245 ft• #2 GRAVEL POUR
Experimental Technology D Subsidence Control ft. ft.
Geothermal(Closed Loop) QTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heatin Cooling Return) [IOther(explain under#21 Remarks) FROM TO DESCRIPTION(color.hardness,soil/rock type,grain size,etc.)
0 ft• 23 it CLAY
4.Date Well(s)Completed:08/21/24 Well ID# 23 ft• 42 ft• SAND ANDCLAY
5a.Well Location: 42 ft• 50 ft SAND
MIQUELITO MCKOY 50 ft• 51 ft ROCK(SOFT) • _..
Facility/Owner Name Facility ID#(if applicable) 51 ft• 60 ft• SAND n U(U 2 & 2024
177 HIAWATHA DR BURGAW 28425 60 ft. 61 ft. h1 ROCK 12"
Physical Address,City,and Zip 61 ft• 90 ft• CLAYH Irr`u:7;-r,. ." : .' ^.:f ' "_di"
t
PENDER 21.REMARKS d•«t.:, t�3
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:
34.605097 -77.925668
w' 1--,--09 f? /c 08/27/24
6.Is(are)the well(s)0x Permanent or �I7'emporary Signature of Ce ed Well Contractor Datc
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 XQNo with 1SA 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 1/21 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: 246 (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@100') construction to the following:
10.Static water level below top of casing:39 (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.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)25(50) Method of test:AIR 24c. For Water Sunnis,&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: 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

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FROM TO (CLAY, SAND, ROCK, ETC.) FROM TO CLAY SAND. ROCK ETC
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