GW1--06680_Well Construction - GW1_20241108

E . Print Form
W11LL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor� Information:
LLOYD D MARES ,14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft. 1
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. 156 ft• 4 in• „4.0 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 TOr DIAMETER SLOT SIZE THICKNESS MATERIAL
*Agricultural QMunicipal/Public 156 ft• 176 ft 4 in' .016 PVC
N Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft ft. in.
®Industrial/Commercial DResidential Water Supply(shared) 18.GROUT ,
X'Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
. _ Non-Water Supply Well: __ __ ——___ .-0---_ft•:_ .20- -ft—-HOL-ERL--UG=POUR—-•— - -------
*'Monitoring D Recovery ft. ft.
Injection Well:
ft. ft.
f'Aquifer Recharge 0 Groundwater Remediation
� 19.SAND/GRAVEL PACK(if applicable)
It Aquifer Storage and Recovery Di Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
®'Aquifer Test DStormwaterDrainage 155 ft• 176 It #2 GRAVEL POUR
*Experimental Technology D Subsidence Control ft. ft.
*Geothermal(Closed Loop) QTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM • TO. DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
*Geothermal(Heating/Cooling Return) nOthei(explain under#21 Remarks) 0 ft 15 ft SAND
4.Date Well(s) 9/4/24 Completed: Well ID# ' ' 15 ft• 23 _ft. `4
SAND/CLAY ;.—.L'a,11•s,!;,.,, ,,;)
Sa.Well Location:W 23 ..,k 35 ft., ''CLAY; nioy fr 4: 9fl)
DOUG BATCHELOR. 35 ft.
V r_ L7
45 ft., SAND/CLAY
Facility/Owner Name ' ' - Facility ID#(ifapplicable) 45 .ft• 89 ft• CLAY:. IG.f.:3:�`:^.. :c ''"r�:r,z:::� • is!-.:OCTOBER GLORY WALLACE NC 28466 89 ft- '101 ft. 'ROCK/SAND(MED)' ' '' '''l'''
Physical Address,City,and Zip 101 ft. 108. ft. SAND,(M E D)
DUPLIN 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: '
34.752603 N —77.937260 W 1 f 0VP �/�3' 10/1/24
6.Is(are)the well(s) Permanent or [j Temporary Signature of Ce ed Well Contractor Date
_ __ _ - .,_ _ . .. ___ _ By signing this form,I hereby certifii that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or !X No with ISA NCAC-02C.0100 or 15A NCifC 02C:02-00-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: 1 76 (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@l00') construction to the following:
10.Static water level below top of casing:26 (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 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: 80Z 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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CUSTOMER: :1 . •- ADDRESS:
THICKNESS FORMATION THICKNESS FORMATION
FROM TO (CLAY, SAND,ROCK,ETC.) FROM TO (CLAY, SAND, ROCK,ETC.)
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