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Home My WebLink AboutGW1--05603_Well Construction - GW1_20240916 Print Form I __.._.._-- . WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: j 1.Well Contractor Information: - I I Lloyd Mares 14.WATERZONES 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) Register Well Co. Inc FROM TO DIAMETER THICKNESS MATERIAL 0 ft. 99 ft. 4 in. .40 pvc Company Name Y 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.) 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 DMunicipal/Public 99 ft. 119 ft. 4 1D' 016 pvc Geothermal(Heating/Cooling Supply) I..'�.Residential Water Supply(single) ft. ft. in. Industrial/CommercialResidential Water Supply(shared) Is.GROUT X Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT Non-Water Supply Well: 0 ft. 20 ft. hole plug pour pMonitoring QRecovery ft. ft. TTInjection Well: ft. ft. *1 Aquifer Recharge 0 Groundwater Remediation - . - - 19.SAND/GRAVEL PACK(if applicable) $i Aquifer Storage and Recovery EI Salinity Barrier FROM , TO , MATERIAL EMPLACEMENT METHOD II Aquifer Test El Stormwater Drainage 98 ft• 119 ft• #2 gravel pour ®Experimental Technology QSubsidence Control ft. ft. ®I Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary) in Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock lyp.Brain size,etc.) 0 ft• 50 ft. sand , 4.Date Well(s)Completed:08/28/24 Well ID# 50 ft• 78 ft• sand and clay r•-• • Sa.Well Location: 78 ft. 85,,' ft. Sand medium fine i e`-*''A's"'`i �'r "'- •Riverlanding Bldrs 85 . ,f' .86 ,ft• rock 12" SFP 1 „ ?(124. Facility/Owner Name Facility ID#(if applicable) 86 ft .94 . ft• sand: . .' 128 Falls Landing Way Wallace NC 28466 94 ft. 96 ft, rock 2'hard liv3:;,-,k:,t::ar' ;°'r:'•�•..v-•y ur,/ Physical Address,City,and Zip 96 ft• 110 ft• sand medium Duplin 21.REMARKS 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: 34.741785 N -77.931232 W 0 / 9/11/24 6.Is(are)the well(s) Permanent or Temporary Signature ofC 'fled Well Contractor Date iX. By signing this form,I hereby cert fy that the well(s)was(were)constructed in accordance 7.Is this a repair to an existing well: 'Yes or IX,No with 15A NCAC 02C.0100 or 15A 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 I 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: 1 19 (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@I00') construction to the following: 10.Static water level below top of casing: ,d (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) 35 Method of test:air 24c. For Water Slimily&Injection 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 //iSF® C . P .I r.. i ,=r a" W ciii6e,,,,„,.. Aid C>)--Off''' 44'4)'. CT '`' FORMATION THICKNESS FORMATION - FROM TO. iftLAY.SAND,ROCK,ETC.) FROM TO •- (CLAY,SAND,ROCK.ETC.) • 1.1, : ' 457' 6, 16. . ,:: .,-,-:,. .-44'2,-(..4,./(i.‘ , f i ., : ,, , , i ''-' ' 1-ir itc ' 1' -Coti-e .- An P''''Ano-----' . , 25:-: 44.. 17.paist- *... .,,'/,, .,i( A ': g4 : '' 9*- if'girrIr ' z J gi,-. . q „ . , , (::&s' . In' -f)1 11.6 i i if 1 -. i 11.4,-,--/h. .11::--......- • 1 - r 5 I- 641,1Y i flG r �r i i4EtY Iget ' sy.ft.i.-itielov• . - , ..: , • I. 1;