GW1--06413_Well Construction - GW1_20241025

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
c, iY+ 1.Well Contractor Information:
LLOYD MARES 14.WATER ZONES
Well Contractor Name FROM , TO DESCRIPTION
2547-A ft. ft.
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 I MATERIAL
0 ft. 65 ft• 4 .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): ft ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
®Agricultural 0Municipal/Public 65 ft. 85 ft. 4 in' .016 PVC
®Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
"Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
1 I Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 ft• HOLEPLUG POUR
®'Monitoring 0 Recovery ft. ft. _ __ _
Injection Well:
ft. ft.
$Aquifer Recharge O Groundwater Remediation .
� 19.SAND/GRAVEL PACK(if applicable)
®1Aquifer Storage and Recovery L'�J'Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
111 Aquifer Test DStormwater Drainage 64 ft• 85 ft• GREAVEL#2 POUR
Ii Experimental Technology D Subsidence Control ft. ft.
l Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type•grain size,etc.)
111 Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) 0 ft. 4 ft. SAND
4.Date Well(s)Completed:9/24/24 Well ID# 4 ft. 7 ft. CLAY
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Sa.Well Location: 7 ft. 9 ft. ROCK ' •t' �.' •.-. 'r '.'.1.:,::.
LARRY HONEYCUTT s ft. 36 ft. SAND OCT 2 2024
Facility/Owner Name Facility ID#(if applicable) 36 ft• 41 ft• CLAY
440 PENNY TEW MILL RD ROSEBORO. NC 28382 41 ft. 48 it SAND lr,:,: -r- :)7^,1.9.;;'-.-,J Ur!
Physical Address,City,and Zip 48 ft. 62 ft. CLAY
SAMPSON 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:
35.108854 N -78.488952 W
6.Is(are)the well(s)1: Permanent or [jTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
- 7.Is this.a repair-to an existing well: Lj- Yes or iONo 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 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: 85 (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
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13a.Yield(gpm) 50 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
i 13b.Disinfection type: HTH Amount: 6 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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