GW1-2021-01051_Well Construction - GW1_20210826

�wn
WELL CONSTRUCTION RE •RD ,
NORTH CAROLINA
EnWronmental Quullty
•rm GW­1 Well Construdon Electronic •
North Carolina Department of En\Aronmental Quality
April 1,2021
Submission ID#
G W 1-2021-01051
Are you submitting a printed form?* r Yes
C No
CONTACT INFORMATION
.........................................................................................................................
Contact Name* Email Address*
Lynn Oliver [e-mail]
Is this a revision to the form you have previously submitted?
r Yes F 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#:
21-113
List all applicable well construction permits(i.e.IVbnitoring Wells,UIC,County,CCPCUA etc.)
What type of well is this?* C Injection Well C Non-Water Supply Well
r Water Supply Well(includes irrigation wells)
3.Water Supply Well* r Geothermal(Heating/Cooling Supply) C Industrial/Commercial
r Irrigation C Municipal/Public/Community
r Residential Water Supply(single) C Residential Water Supply(shared)
r Wells>100,000 GPD
4. Date well was completed and ID#
Date Well Completed* Well ID# Well Yield
7/27/2021 23
(gallons per minute)"

5.Well Location
Facility/Owner Name
Randal Blake Davis Facility ID#
(Required) (If applicable)
County* Parcel Identification No.(PIN)
Union 03-177-009C
Physical Address* Street Address
4525 Belk Mill Road
Address Line 2
City State/Province/Region
Monroe NC
Postal/ZZp Code Country
28112 US
Latitude* 34.8712812000 Longitude*80.4443605000
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 explain 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
300 surface?
Formultiplewells Iistall depths if different 46
(example-3@200'and 2@100') in feet
10.Static water level below top of casing:(ft.) 11. Borehole diameter:
27 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)
23 13a. Method of test:
If applicable Air
13b. Disinfection type:* 13b.Amount:*
70%HTH 18 oz
14.WATER BEARING/FRACTURE ZONES

From To Description
104,186,218 in feet
in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
From To Diameter Thickness Material
0.00 46.00 6.25 SDR21 PVC
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(15)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 7.00 Brown Clay
in feet in feet
7.00 300.00 Blue Slate
in feet in feet
21.Remarks
22.Site diagram or additional well details:
You mayupload additional well construction information here.
pdf only
CERTIFICATION INFORMATION
*PF 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*
vtaWI&O ae ok6kt
Signature of Certified Well Contractor

Submittal Date 8/26/2021