GW1-2021-01717_Well Construction - GW1_20210323

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver Is.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
3002-A 235 n' 428 n
562 n' 612 n'
NC Well Contractor Certllicatian Number It OUTER CARING OR'
Carolina Well Drilling FROM TO DIAMETER aFIICRNE88 MATFAMI.
Company Name 0 n. 53 n. 61/8" In. SDR21 PVC
It INNER CASING OR 20-524 a
2.Well GOIIBITIIctian Permit N: FROM TO DIAMETER THICKNESS I MATERIAL
Litt all applicable sell construction peonies(i.e.UIC,County,Sole,Variance,etc.) n. R. Ia
3.Well Use(check well use): I,
rA
Su I Well: 17.
SCILEAN
PPY mom TD DIAMETER aWTRIM THICKNESS MATERIII,
ultural OMunicipaVPublic 0 R fL Ia
hermal(Heating)Cooling Supply) ®Residential Water Supply(single) R fu Ia
triaUCommemial OResidentid Watu Supply(shared) IL GROW
ation PROM TO MATERIAL MEr'it0 aAMOUNTater Supply Well: 0 n' 20+ ILBentonite Pour 14.5 501b Bags
itoring RecoveryfLon el: 0. ft.
fer Recharge OGmundwater Remediation
! PfU SItN'age and Recovery' O$8linity Gamier iROM TOENT METHOD
fer Test OSlormwater DrainagefL Rrimental Technology OSubsitlencec Control 'Lermal(Closed Loop) QTracer 2N.umal(Heatin Coolies Return) Other(explain under#21 Remarks mom
To DEacRImnN aor.h.ra avroet t raa eo.
0 n' 6 n. Brown Clay
4.Date Well(s)Completed: 2-2-2021 Wd1 IDN 6 D' 35 n' Brown Clay/Rock
5a.Well Location: 35 n. 650 n.
Vladimir Podrez
Facilit-v/Owmr Nanx Fudily IDl'(if applicable) n' n'
1414 Witmore Rd.Wingate 28174 Lot#1 D. n. p
Physical Address,City.and Zip ft. h i.
Union 09-031-005 21.RKbtARJU1
Cauery Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or tied=]degrees:
(if well field,one hullong is sufficient) 22.Certification:
34.57.016 N 80.26.981 W,
•� 2-24-2021
6.10m)the well(SQPernsanenl or QTemporary Signature of Certified Well Contractor Date
By signug this Iona I hereby v,,ob dual the-ell(s)was(sere)cotmrmcted in darordwtce
7.Is this a repair to an existing well: Oyes or 63No a ith 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construct,"Standards and The,a
J rhi,a a repair,J'IIOY(kna1M xrll IXMnNOIan infornsOnon and eAphou the nature of the copy of this record has been provided to the sell corner.
repair mu4r#21 remarks section or on the frock of this form.
23.Site diagram or additional well details:
S.For Gecprobe/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 I OW-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: 650 (DJ 24a• For All Wells: Submit this form within 30 days of completion of well
For nrulripL xrl/s list ail drPths iJdD rant(rruntPlr-3@200'and 2(a100 construction to the following:
10.Static water level below tap of casing: 16 (ft.) Division of Water Resources,Information Processing Unit,
If nester level is abate casing,use"� 1617 Mail Service Center,Raleigh,NC 27699.1617
11.Borehole diameter: 6 (In.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Air Rotary above, also submit one copy of this form within 30 days of completion of well
IL Well construction method: construction to the following:
(Le.auger,rotary,cable,duem push.etc.)
Division of Water Resources,Underground INection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699.1636
13a.Yield(gpm) 25 Method of test: Air 24c.For Water Supply & Initiation We1L: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13K Disinfection type: 70a/o HTH Amount: 400z completion of well construction to the county health department of the county
where constructed.
Fomi GW.t North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016