GW1--05894_Well Construction - GW1_20241001

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1 tWeII Contractor Information:
LLOYD MARES 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
2547-A
ft. ft.
NC Well Contractor Certification N umber A I 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
REGISTERWELL CO.,INC FROM TO I)LUIF.I'ER THICKNESS MATERIAL
0 ft' 207 ft 4 in. I.40 pvc
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2 Well Construction Permit#: 1 FROM TO DIAMETER . THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft ft t°'
3.Well Use(check well use): ft ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
x Agricultural ['Municipal/Public 207 ft 307 ft 4 1n. .016 pvc
Geothermal(Heating/Cooling Supply) 0 Residential Water Supply(single) ft. ft. in.
industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT _
Irrigation FROM TO V AT E RI.1 I. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft hole plug pour
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge El Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test IDStormwater Drainage 206 ft 307 ft• #1 gravel gravel
Experimental Technology 0 Subsidence Control ft. ft.
Geothermal(Closed Loop) ElTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soitlrock type,grain size,etc.)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) t
0 ft 9 ft sand and clay , • -
4.Date Well(s)Completed:7/30/24 Well ID# 9 f`' 38 f`' Clay , ` ,• •.' •ii-'�
ft. 45 ft. merle soft tit
j (I ....4,....4,44,
5a.Well Location: 38
45 ft 59 ft merle hard lr,;,,•• 1 2024
Andy Nguyen K,;,r.,
Facility/Owner Name Facility ID#(if applicable) 59 ft 117 ft merle soft dui:,, •
..`• - 1
481 Eneas Lanier Rd Chinquapin NC28521 117 f`• 139 sand and clay '`"�
Physical Address,City,and Zip 139 ft 146 ft rock sand and clay _
Duplin 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22.Certification:
34.824797 N -77.724621 W !J CYP 71/1,4/ '_ 19.21
6.Is(are)the well(s)JPermanent or Temporary Signature of C ed Well Contractor Date
By signing this form,I hereby certifi,that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or pNo 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 nd 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 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: 307 (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:56 (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 Iniection 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) 50 Method of test: air 24c. For Water Slowly& 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: 6 OZ completion of well construction to the county health department of the county
where constructed.
Form G W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

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