GW1--05267_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 malts-cased wells)OR LINER(if a • ble)
Mcpherson Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
R
0 . 178 ft• 2 i°' 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,County.State,Variance,etc.) It. ft. in.
3.Well Use(check well use): rt. ft. In.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 178 ' 188 n. 2 in. 8 sch40 pvc
OGeothermal(Heating/Cooling Supply) ClResidential Water Supply(single) k. 178 k, in.
❑Industrial/Cormaercial ❑Residential Water Supply(shared) 18.GROUT
❑irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 3 k• cement pour
❑Monitoring ❑Recovery 3 k• 100 ft. bentonite tremmie
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test OStormwater Drainage 100 k. 188 k• 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/rocktspe,gnus sirx,etc.)
0 k• 25 ft• sand
4.Date Well(s)Completed: 8/21/24 Well ID# 25 k• 90 IL clay
5a.Well Location: 90 k• 120 fi' sand r
James&Wanda Register 120 k• 160 fL day F ` i -., / :--
Facility/Owner Name Facility KM(if applicable) 160 k• 188 k. sand
10575 New Britton Hwy Whiteville NC 28472 ft. ft SEP 0 6 20Z4
Physical Address,City,and Zip ft. ft
Ifl/erfriiistn Prr,c r9 U+it
Columbus 21.REMARKS OW40906
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.Ce if ation:
N W & 8/21/2024
6.Is(are)the well(s): �Permaneet or ['TemporaryS' of fled W ntractor 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: ❑Yes or 1!1No ISA NCAC 02C.0100 or I SA 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#11 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-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 188 (ft.) Submit*Ms GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3@200'and 1@100')
Static water level below of casing:20 (It.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10. Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
It 10. level is above casing,use top
11.Borehole diameter: 8 (lo,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rotary
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
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 20 Method of test: Air
13b.Disinfection type: Granular Amount: 1/8 lbs