GW1--05946_Well Construction - GW1_20241009

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' WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1',Well Contractor Information:
Lloyd Mares 14.WATER ZONES '
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
Company Name 0 ft. 60 ft. 1 4 ;, 1° .40 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.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 60 ft' 80 ft. 4 in' .016 pvc
*Geothermal(Heating/Cooling Supply) Iz Residential Water Supply(single) ft. ft. in.1'
It Industrial/Commercial IDResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 ft. hole plug pour
*Monitoring QRecovery ft. ft.
Injection Well:
ft. ft.
it Aquifer Recharge 0 Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
*Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
R Aquifer Test DStormwater Drainage 59 ft. 80 ft' gravel#2 pour
®Experimental Technology IDSubsidence Control ft. ft.
®;Geothermal(Closed Loop) ITracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soit/rocletype,.grain size.etc.)
a Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks)
0 ft. 16 ft, sand ab.. : a J ,
4.Date Well(s)Completed:09/23/24 Well ID# 16 ft. 19 ft. clay ,r 3
5a.WellLocation: 19 ft' 45 ft• sand: OCT ) J 2024
zACK wILLIS 45 ft. 57 ft. clay Ire:;, _i ,-
Facility/Owner Name Facility ID#(if applicable) 57 70 sand medium coarse L"2<-'��
169 Fox Run Dr. Autryville NC2 28318 70 ft, 76 ft. clay w sand layers
Physical Address,City,and Zip 76 ft• 80 ft• sand medium
sampson 21.REMARKS '
County Parcel Identification No.(PIN) _
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -
(if well field,one latllong is sufficient) 22.Certification:
35.008691 N -78.634682 W
L,Z--Q i 9/30/24
6.Is(are)the well(s)FX'..Permanent or I©ITemporary Signature of Cerf d Well Contractor Date
By signing this form,I hereby certfy that the well(s)was(were),constructed in accordance
7.Is this a repair to an existing well: QYes or iX No with 15A NCAC 02C.0100 or ISA 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 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: 80 (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@100') . construction to the following: j
27
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10.Static water level below top of casing: (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) 50(75) Method of test:air 24c.For Water Supply&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

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THICKNESS . FORMATION THICKNESS I FORMATION
FROM TO .! (CLAY,_SAND,.ROCK,ETC.) FROM TO (CLAY,SAND,ROCK,ETC.)
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