GW1-2021-04712_Well Construction - GW1_20210527

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver :ta.wAER zoNEs
FROM TO DFSCRIPTION
Well Contractor Name
127 ri. 170 ft.
3002-A ft, rt
NC Well Contractor Certification Number wt5r`pl1TER;CASING:for fnulti cased'aelIS)'OR;GINCR'iES"'ftrable i,
Carolina Well Drilling FROM TO DIAMRTRIt THICKNESS MATERIAL
0 n' 18 n. 10 In. SDR21 PVC
Company Name
:16+ ER-CASING OR TUBING @othekmal closed466
2.Well Construction Permit#: 57825 FROM I TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permit'(i.e.UIC.County,State,Variance,etc.) 0 IL 110 h' 6 1/8 in. SDR21 PVC
3.Well Use(check well Ilse): ft. n in
Water Supply Well: FROM I TO I DIAMETER SIATSI'LE THICKNESS MATERIALr'
Agricultural 13Municipal/Public 0 n. ft. In.
Geothermal(Heating/Cooling Supply) JaResidential Water Supply(single) ft, ft. in.
Industrial/Commercial Residential Water Supply(shared) t.
"Irrigation FROM TOt I MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 n 18 it Bentonite Pour 6 501b Bags `10"
Monitoring DRecovery 0 n- 20+ rL Bentonite Pour 10 501b Bags`6 1/8"
Injection Well: ft. ft.
Aquifer Recharge 13Groundwater Remediation
"19:�SAND/GRAV9L-RACK"lf:a "ticable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ostormwater Drainage ft. n.
Experimental Technology Subsidence Control n•
Geothermal(Closed Loop) OTracer r xO4,DRILLING'CV attachsdditloneh'streets`dPiieceasa
FROM TO DESCRIPTION(color,hardness,softfrock type, rain sire etc.
Geothermal(Heatin /Conlin Return) Other(explain under#21 Remarks)
0 ft 18 n' Brown'Sand/Gravel
4.Date Well(s)Completed. 4-28-2021 Well iD# 18 rL 46 It White/Gray Clay
5a.Well Location: 46 ft. 67 rL
Red Clay
Christa Nicholson 67 rL 85 ft, Brown Clay
Facility/Owner Name Facility IDli(if applicable) 85 n' 97 ft GrayCla
1577 US#1 South Rockingham 28379 97 n' 400 n Blue Slate/Granite
Physical Address.City,and Zip
744000527528
Richmond -
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: V i11t
(if well field,one lat/long is sufficient) 22.Certification:
34.51.182 N 79.50.857 W ^"� U�11� 5-5-2021
6.Is(are)the well(s) Permanent or OTemporary
Signature of Certified Well Contractor Date
By signing this./arm, 1 hereby certy5-that lite ell(s)%,us(were)consovcted in accordance
7.Is this a repair to an existing well: ®Yes or ONo with 15A NCAC iv
02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction it fornwtion 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 this fonn. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the some You may use the back of this page to provide additional well site details or well
construction,only I GW-t 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: 400 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if di,Q'erent(example-3Q200'and 2@1001 construction to the following:
10.Static water level below top of casing: 78 (ft.) Division of Water Resources,Information Processing Unit,
1f water level is above casing,use"+" 1617 Mall Service Genter,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 form 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) 1.5 Method of test: Air 24c.For Water Supply&Iniection Wells: In addition to sending the forni to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 70%HTH Amount: 24oZ completion of well construction to the county health department of the county
where constructed.
Font GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016