GW1-2021-04531_Well Construction - GW1_20210429

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver 1a.wA1R.zzoNEs . ; i .
Well Contractor Name 9 FROM TO DESCRIPTION
3002-A
RECFD 70 re. 91 n
,
APR 2 9 2021 236 n. n
NC Well Contractor Certification Number 15..oL 1'F.R CASING for md]04tased ells(OR LINER'IRA` Iicable
Carolina Well Drilling OM TO DIAMETER THICKNF$3 MATERIAL
LIT
Company Nam Ifi;,f17 art n• 45 iL 6 1/8"1 In. SDR21 PVC
D1,NR 5ect:O" 16.%u9l+lER"CA ING OR TUBING'"etitherttial i losed-Ito
2.Well Construction Permit#i: 18-126 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIG County,State,Variance,etc.) n. ft. i in.
3.Well Use(check well use): n• n. In.
Water Supply Well: FROM FROM EFN TO DIAMETER
AMFTFR ' SLOT S17F THICKNN.S.S MATRRIAI.
Agricultural [3MunicipaVPublic 0 n. n. in.
Geothermal(Heating/Cooling Supply) laResidential Water Supply(single) ft. n- In.
IndustriaVCommercial Residential Water Supply(shared) i 18 GROUT.
lirriization FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 n• 20+ fL Bentonite Pour 15 501b Bags
Monitoring _ Recovery n. n.
Injection Well:
n. n.
[Experimental
uifer Recharge Groundwater Remediation
:)19.=SANDIGRAVA Pk'CK'(tt` 'pcable
uifer Storage and Recovery Salinity Barrier FROM TO MATERIAL FMPLACEMENT METHOD
uifer Test ElStormwater Drainage ft. fL
Technology Subsidence Control n• rGothermal(Closed Loop) Tracer :2t) DRILLING.IAG'atift addltiontil,sheets IPFROM TO DESCRIPTION color hardness soll/rock t in size etc.othermal(Hearin Coolin Return Other(explain under#21 Remarks)
0 ft. 16 fL Brown birt/Rock
4.Date Well(s)Completed: 3-31-2021 Well ID## 16 it- 250 n• Granite
5a.Well Location:
Leon Blakeney n. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
2102 Rock Rest Rd. Wingate 28174 ft. fL
Physical Address.City,and Zip ft. fL
fz1 REMARKS•"t
Union 02-251-002
County Parcel Identification No.(PIN)
5h.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
34.56.491 N 80.26.488 W 4-6-2021
Signature of Certified Well Contractor Date
6.Is(are)the well(s) Permanent or Temporary
By signing this form, I hereby cert#fy that the imll(s)nuts(%wre)constructed in accordance
7.Is this a repair to an existing well: 13
Yes or RNo n•irh 15A NCAC 02C.0100 or 15A NCAC 02C.0200 IVM Construction Standards and that a
If this is a repair,fill our knomi well construction h1fornuuion and explain rite nature of the copy of this record has been provided to the well owner.
repair under N21 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 I GW-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: 250 (ft-) 24a, For All Wells: Submit this form within 30 days of completion of well
For tmdtiple wells list all depths if different(example-3Q200'and 2®100') construction to the following:
10.Static water level below top of casing: 10 (N Division of Water Resources,Information Processing Unit,
If nester level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
r
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.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Uudergrouud Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,INC 27699-1636
i
13a.Yield(gpm) 13 Method of test: Air 24c.For Water Suonly&Iniection Wells: In addition to sending the forms to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 70%HTH Amount: 150z completion of well construction tot the county health department of the county
where constructed. 1
Fort OW-I North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2.22-2016
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