GW1-2021-00118_Well Construction - GW1_20210611

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WELL CONSTRUCTION RE •RD ,
NORTH CAROLINA
EnWronmental Quullty
•rm GW­1 Well Construdon Electronic •
NorthCarolina Department of •
Division
April 1,2021
Page 1
Submission ID#
GW 1-2021-00118
CONTACT INFORMATION
..................................................................................................................................... ........................................................................ .........
Contact Name* Email Address*
Lynn Oliver [e-mail]
Is this a revision to the form you have previously submitted?
f Yes r No
WELL CONSTRUCTION INFORMATION
........................................................................................................................................................................................................................................................................................................................................................................................................................................................
1.Who is installing these wells?*
r Owner r Well Contractor
1.Well Contractor Information:
Certiticate# Cert Level First Name Last Name Company Name
3002 A FRANKIE OLIVER CAROLINA WELL DRILLING
2.Well Construction Permit#:
19-333
List all applicable well construction permits(i.e.fvbnitoring Wells,UIC,County,CCPCUA etc.)
What type of well is this?* r Injection Well r Non-Water Supply Well
r Water Supply Well(includes irrigation wells)
3.Water Supply Well* r Geothermal(Heating/Cooling Supply) r Industrial/Commercial
r Irrigation r Municipal/Public/Community
r Residential Water Supply(single) r Residential Water Supply(shared)
r Wells>100,000 GPD
4. Date well was completed and ID#
Date Well Completed* Well ID# Well Yield
6/14/2021 25
(gallons per minute)"

Page 2
5.Well Location
Facility/Owne r Name*
Joseph Jordan Facility ID#
(Required) (If applicable)
County* Parcel Identification No.(PIN)
Union 06-045-034A
Physical Address* Street Address
Mill Pond Acres Lot#5
Address Line 2
City State/Province/Region
Weddington NC
Postal/ZZp Code Country
28104 USA
Latitude* 35.0058100000 Longitude't0.4149300000
Decimal degrees Decimal degrees
6. Is(are)the well(s):* r Permanent r Temporary
7. Is this a repair to an existing well:* r Yes r No
If this is a repair,fill out known well construction information and a)plain the nature of the
repair under#21 remarks section or on the back of this form.
For multiple Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction,only 1 GW-1 is needed.
8a. Indicate TOTAL NUMBER of wells drilled: 1
9.Total well depth below land surface:(ft.) 9a.What is the depth of the casing from ground
200 surface?
For multiple wells Iistall depths if different 43
(example-3 a200'and 2@100') in feet
10.Static water level below top of casing:(ft.) 11. Borehole diameter:
10 6
If water level is above casing,use"+" in inches
12.Well construction method:
r Auger r Air Rotary r Cable Tool
r Direct Push r Mud Rotary r Rotosonic
r Other
13. FOR WATER SUPPLY WELLS ONLY:
13a.Yield (gpm)
25 13a. Method of test:
If applicable Air
13b. Disinfection type:* 13b.Amount:*
70%HTH 12 oz

Page 3
14.WATER BEARING/FRACTURE ZONES
From To Description
95 in feet
in feet
113 in feet
in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
From To Diameter Thickness Material
0.00 43.00 SDR21
in feet in feet in inches
17.SCREEN
From To Diameter Thickness Material
in feet in feet in inches
18.GROUT
................
From To Material Emplacment Method &Amount
0.00 20.00 Bentonite Pour(14)501b Bags
in feet in feet
19.SAND/GRAVEL PACK(if applicable)
From To Material Emplacment Method
in feet in feet
20.DRILLING LOG
From To Description (color, hardness, soil/rock type, grain size,etc.)
0.00 4.00 Brown�,iay
in feet in feet
4.00 25.00 Brown Dirt/Rock
in feet in feet
25.00 200.00 Granite
in feet in feet
21.Remarks
22.Site diagram or additional well details:
You may upload additional well construction information here.
pdf only

*rJ By signing this form, I hereby certify that the well(s)was(were)constructed in accordance with 15A NCAC 02C
.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy of this record has been provided to
the well owner.
23.Certification*
Signature of Certified Well Contractor
Submittal Date 6/11/2021