GW1-2021-01482_Well Construction - GW1_20210429

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver 14':-WATER ZONES „
Well Contractor Name FROM TO DESCRIPTION
113
3002-A 92 ft. f°
157 et. ft
NC Well Contractor Certification Number 15:"OITIER CASING for multi ciiM wetls)OR INNER(if a= lieable)s a
Carolina Well Drilling FROM TO I DIAMETFR THICKNESS MATERIAL
Company Name 0 ft' 47 ft' 61/8" '"' SDR21 PVC
�46ANNER CASING OR TUBING eothermal closed-too <°.
2.Well Construction Permit#: 19-249 FROM TO DIAMETER THICKNESS MATERIAL.
List all applicable well construction pennitr(i.e.U1C,County,State,Variance,etc.) A. ft. in.
3.Well Use(check well use): ft. fL in.
Water Supply Well: M SCREEN.
FROM TO DIAMETER SIOTSI'LE THICKNESS MATERIAL
Agricultural Municipal/Public 0 ft. ft in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft, ft. in,
Industrial/Commercial OResidential Water Supply(shared) ;1g:GROIIT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20+ fL Benton'ite Pour 15 501b Bags
Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAN1)lGRAVEL PACK(if lleabie)%.' •'
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessar "s
Geothermal(Heating/Cooling Return) MOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiVrock type,grain sim,etc.)
0 ft' 6 f`' Red Clay
4.Date Well(s)Completed: 3-23-2021 Well ID# 6 ft• 21 ft' Brown:.Dirt/Rock
5a.Well Location: 21 ft. 200 IL Granite
Ramona Matthews ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
3700 Deer Hollow Dr.Gold Hill 28071 Lot#1 ft. M
Physical Address,City,and Zip
Cabarrus 21sREMARKS S;, np ``
County Parcel Identification No.(PIN) P` v�
P(0
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: A
(if well field,one lattiong is sufficient) 22.Certification: \0001"Q4"R
35.28.040 N 80.19.282 W
4-12-2021
6.Is(are)the well(s) Permanent or Temporary Signature of Certified Well Contractor Date
By signing this form, I hereby certify that,the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [)Yes or Eallo with 15A NCAC 02C.0100 or 15A NCAC 62C.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[his 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-I 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 (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 1@100') construction to the following:
10.Static water level below top of casing: 30 Division of Water Resources,Information Processing Unit,
If water level is above casing,:tse"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
Air Rotary above, also submit one copy of this iform 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) 30 Method of test: Air 24c.For Water Supply&Iniection 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: 70%HTH Amount: 12oZ completion of well construction to the county health department of the county
where constructed.
Fonn GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016