GW1--05261_Well Construction - GW1_20240906

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: ,
Hugo Rivas 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
3159
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a lIcable)
Mcpherson Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft- 208 ft. 4 in. sch40 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,Comity,State,Variance,etc.) ft. ft. m.
3.Well Use(check well use): ft. ft' In.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SITE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft in
❑Geothermal(Heating/Cooling Supply) L'IResidential Water Supply 2O8 228 12 sch40 pVC
(H g( g uPP Y) uPP Y ft• 208 ft• r in,
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑lrrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 3 f'' cement pour
❑Monitoring ❑Recovery 3 ft. 100 ft' bentonite tremmie
Injection Well:
ft. ft.
El Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL F:M PLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 100 ft' 228 ft' gravel#1 pour
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soil/rock type brain size,ete.)
0 ft' 25 ft. sand
4.Date Well(s)Completed: 8/3/24 well ID# 25 ft- 110 ft. clay
5a.Well Location: 110 ft' 120 ft• sand
�•" '
James Floyd Ward 120 ft. 198 fll' day r;`�'L:,: ��I
Facility/Owner Name Facility ID#(if applicable) 198 ft' 228 ft• sand 1t"'1./'
578 Arm Ward Rd Whiteville NC 28472 ft. ft. StP 0 6 2024
Physical Address,City,and Zip ft. ft.
Columbus 21.REMARKS i�ofm�i+ei i'.r0. t,that
DWCAROG
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.Certifcation:
N W 4/4 0,- 8/3/2024
6.Is(are)the well(s): ]Permanent or ❑TemporarySi/% 4
re of fled Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yea or tiNo ISA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the 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 construction info
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Ova'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:228 (R') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q200'and 2Q100')
10.Static water level below top of casing: 50 O 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter:8 (�) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rota•lr�/ 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable.direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpao Method of test: Air
80 Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Bfectiontype: Granular Amount: 1/8 lbs