GW1-2021-03045_Well Construction - GW1_20210622

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver � ti `': ';'s;' x
FROM TO DESCRiPTION
Well Contractor Name
128
3002-A a
NC Well Contractor Certification Number Y ti _. iCe' GI IJR)I31. (!' '11had10
Carolina Well Drilling FROM TO DIAMIM c TMCKNEI MATERIAL
0 n' 47 n' 6 1/8n In. SDR21 PVC
Cvmpeny Name
2.Well Construction Permit#: 20-579 FROM To ]DIAMETER THiCKNM MATP.RiAL
List all applicable Kull construction permits p.e.U1C,County,Stare,Variance,etc.) n• (L In.
3,Well Use(check well use): ft. ft. to
Water Supply Well: FRO TO DIAMETER !SLOTSIXER I THICKNESS MATERIAL.
Agricultural r)Municipamblic It. ft. In.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) n• O, In.
Industrial/Commercial 13Residential Water Supply(shared) y 1''x•. l
lrrijt4tion OMTO :yMATERIAL EMI'METHOD&AMQ1UNT
Non-Water Supply Well: 0 �' 20+ n' Sentonite Pour 13 501b Bags
Monitoring 1311ccovety ft. R.
Injection Well: ft. p•
Aquifer Recharge ®Groundwater Remediation
Aquifer Storage and Recovery Salinity Barrier F
ROMTO ATERiAL RMPLACEMENT METHOD
Aquifer Test DStormwaterDrainage ft
Experimental Technology Subsidence Control n•
Geothermal(Closed Loop) Tracer �. ' ck s c�It � c'
Geothermal Heatin Coolin Return Other(explain under#21 Remarks To DESCRIPTION e eobr,Luedneas eoturoekt tndm tic
10 " Red Gla4.Date Well(s)Completed: 430-2021 Well m# 26 So.Well Location: 200n. Qranite
David&Ashley Jolley ft.
Facility/Owner Name Facility ID#(if applicable) it. iL a.+t
7914 Haigler Gin Rd. Monroe 28110 n rL
ft. % v j� cd J
Physical Address.City.and Zip
f
F+s>r'-".k:..� FRi' F�+'S�.y:"r�.3;`'nd•k- .F�;,c r '- " .�'.'•!
Union 08-015-001 G lJ.Ovv �-
County Parcel Identification No.(PIN) '
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 2L Certification:
35.60.843 N 80.25.964 W = 5-21-2021
w ll s Permanent or Temporary Signat�fled Well Contractor Date
6.Is(ore)the a ( )
By signing this form,I hereby cerr(fy that the ur?1!(s)aws(Hrre)constructed in accordance
7.Is this a repair to an existing well: Oyes or MNo with lSA NCAC 02C.0100 or 15A NCAC,02C.0200 Well Construction Standards and that a
If this is a relmir,Jill am known well construction htformation and explain the nature of the Copy gfthis record has been provided to the wetl owner.
repair under N2/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 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: 200 00 24s. For Ail Wells: Submit this form within 30 days of completion of well
For multiple„rils list all depths(jdiiffen nt(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: 17 (fL) Division of Water Resources.information Processing Unit,
if waier level is above caring,use"+" 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in) 24b.For Injection 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
12.Well construction method: construction to the following:
(i&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 2769..9-1636
13a.Yield(gpm) 16 Method of test: Air 24ta Far Water Supply&„Inic0p'n Wells: 1n addition to sending the form to
the address(cs) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 70%HTH Amount: 12o2 completion of well construction to(the county health department of the county
where constructed.
Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22.2016