GW1--05268_Well Construction - GW1_20240906

WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Well Contractor information:
Hugo Rivas 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3159 ft. H.
ft. ft.
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
Mcpherson Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 210 ft. 4 in. sch40 pvc
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.) ft. ft. in.
-
-
3.Well Use(check well use): ft, ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public 210 ft- 230 ft. 4 in• 12 sch40 pvc
❑Geothermal(Heating/Cooling Supply) InResidential Water Supply(single) it 210 ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 3 ft. cement pour
❑Monitoring ❑Recovery 3 ft. 100 ft. bentonite tremmie
Injection Well: - -
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 100 ft. 230 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 sou/rock type grain size,etc.)0
O r�
0 ft' 35 ft- lay
4.Date Well(s)Completed: 8/23/24 Well ID# 35 ft. 90 ft. sand
5a.Well Location: 90 ft. 125 ft- clay •..
Donna &Jeffrey Demos 125 ft- 170 ft- sand �~,`.ti t- .
Facility/Owner Name Facility ID#(if applicable) 170 ft. 205 ft- lay/sand
2306 Slippery Log Rd Whiteville NC 28472 205 ft. 230 ft. sand SEP g 6 2024
Physical Address,City,and Zip ft. ft. Ith(p,•R-. en Prrf
Columbus 21.REMARKS DWCo I
PIt
County Parcel Identification No.(PIN)
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Ce if ation:
N " 8/23/2024
6.Is(are)the well(s): ]Permanent or OTemporary Si tore of ified Well r Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or I,No ISA NCAC 02C.0100 or ISA 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-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if nerncsary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:230 (B•) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2(4100)
10.Static water level below top of casing: 50 ( ) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: 8 (in.)
o Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rita't y 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) 80 Method of test: Air
13b.Disinfection type: Granular Amount: 1/8 lbs
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