GW1--06412_Well Construction - GW1_20241025

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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
2547-A ft ft.
ft. ft. I
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- 64 ft- 4 . in' .40 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.) ft. ft. ; in.
3.Well Use(check well use): et ft. , in.
Water Supply Well: FRO SCREEN
TO DIAMETER SLOT SIZE THICKNESS MATERIAL
®Agricultural DMunicipal/Public 64 ft. 84 ft. 4 in. .016 PVC
N Geothermal(Heating/Cooling Supply) 0 Residential Water Supply(single) ft ft. in.
N Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation • FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Welk__ ___, ____ _. -O fc. _20_ ft-_HOLE PLUG -POUR --
*Monitoring DRecovery ft. ft.
Injection Well: •
ft. ft.
a Aquifer Recharge D Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
®i Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
NI Aquifer Test DStormwater Drainage 62 ft. 84 ft. GRAVEL#2 POUR
mig Experimental Technology 0Subsidence Control ft. ft.
$Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
m Geothermal(Heating/Cooling Return) FlOther(explain under#21 Remarks) 0 ft. 5 ft. SAND
4.Date Well(s)Completed:9/24/24 Well ID# 5 ft. 7 ft' CLAY
-
5a.Well Location: 7 ft. g - ft. ROCK
LARRY HONEYCUTT 8 ft. 35 ft. SAND (COURSE) {- -- _.
Facility/Owner Name Facility ID#(if applicable) 35 ft. 40 ft. CLAY .
•
440 PENNY TEW RD ROSEBORO, NC 28382 40 ft. 47 ft. SAND OCT ? 024
Physical Address,City,and Zip 47 ft. 62 ft- CLAY
SAMPSON 21.REMARKS Ili:,.,,... a { y
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:
35.108909 N -78.488971 W
6.Is(are)the well(s)®IPermanent or Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby cert fy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well IYes or DINo with 15A NCACO2C.0100 or 15A NCAC 02G.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: 84 (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:
10.Static water level below top of casing: 14 (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) 60 - - 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: 6 OZ completion of well construction to the county health department of the county
where constructed. j
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

7 P.
CUSTOMER: Late $9 C, co'f+- ADDRESS:
, / -
THICKNESS FORMATION THICKNESS FORMATION
FROM TO (CLAY, SAND,ROCK,ETC.) FROM TO (CLAY, SAND.ROCK,ETC.)
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