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Home My WebLink AboutGW1--06414_Well Construction - GW1_20241025 Print Form 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. � _ 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' 65 ft• 4 , in' .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.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, 90 ft• 4 in. .016 PVC ®Geothermal(Heating/Cooling Supply) (Residential Water Supply(single) ft. ft. in. 1 Industrial/Commercial DResidential Water Supply(shared) - OM 18.GROUT_ I !Irrigation FR TO MATERIAL _ EMPLACEMENT-METHOD&AMOUNT--r - - Non-Water Sttpply Well: 0 ft• _ 20 ft• HOLPLU_G POUR *Monitoring ORecovery ft. ft. , Injection Well: ft. ft. ®i Aquifer Recharge Ei Groundwater Remediation ' 19.SAND/GRAVEL PACK(if applicable) ill Aquifer Storage and Recovery I Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD ®Aquifer Test D Stormwater Drainage 64 ft, 90 ft• GRAVEL#2 POUR MI Experimental Technology D Subsidence Control ft. ft. I !Geothermal(Closed Loop) D Tracer 20.DRILLING LOG(attach additional sheets if necessary) Geothermal(Heating/Cooling Return) ri Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.) 0 ft- 5 ft, SAND 4.Date Well(s)Completed:9/25/24 Well ID# __ 5 ft• 10 ft CLAY < > Sa.Well Location: 10 ft, 11 ftROCK n. LARRY HONEYCUTT 11 ft• 37 ft. SAND 0L I 1 i. . UZ4 Facility/Owner Name Facility ID#(if applicable) 37 ft• 41 ft• CLAY ,r<_.. .1 ;_•,i ,,F 440 PENNY TEW MILL RD ROSEBORO. NC 28382 41 ft• 49 ft• SAND D'!":c2:t_:3 Physical Address,City,and Zip 49 ft 63 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: 35.108727 N -78.488919 w // i / 10/15/24 6.Is(are)the well(s)0Permanent or Ii Temporary Signature ofC ied Well Contractor _Date ------ - - By signing tliis form;1 hereby certify that the well(s)was(were)constructed in accordance 7.Is this a repair to an existing well: 4EYes or DNo 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: 90 (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: 14.5 (ft.) Division of Water Resources,Information Processing Unit, If water level is above casing,rue"+•-- 1617 Mail Service Center,Raleigh,NC 27699-1617 11.Borehole diameter: 6-3/4 (in.) 24b.For Infection 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.) i Division of Water Resources,Underground Injection Control Program, FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service I Center,Raleigh,NC 27699-1636 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 13b.Disinfection type: HTH Amount: 6 completion of well construction to the county health department of the county where constructed. Fonn GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016 1 . • -,, • • . . . . . • . . CUSTOMER: LQI"- y 14vp...ey c ti:11-4 ADDRESS: ..'VL;) -P et)/v 'lel L,,/ (r);11 qr.) . . . , THICKNESS FORMATION THICKNESS . FORMATION FROM TO (CLAY,SAND,ROCK,ETC.) FROM TO . ; (CLAY,SAND,ROCK,ETC.) D ..S-- ..,. ,/ (......." . . • ee' .,.., / 0 ,...,, t/ . •A.oz..f( • - /,../ .. . . . : . , / i . .- . . • • —v . . ‘, ..> v c't •e:"/Ai?: ___, ' (- r-. ,',•"/.. • - (1-14 e, u ,rir -) . 4 . 6 3 .,,,,...,°/:_:e4t1 , 4 e ,,•,e, -1-• . . • 83-- 1 P ..-56 's/e4y 41.4ire:&•—•': -71-- / ,--,1; ( - . ..... ,, .Z..." 1,..? -,:,,.:-;'-'''. ' i..1 . ,. ' ' • g...,,, . ... , . . .,,... '. '.-71',., • ' . , • :. . . ',. .. , . .... _ . , — . ____ _ ____. ' • . 1 . . . . . . . . . . . . , . , . , . ' . 1 . . i 1 • ' • .