GW1-2021-02588_Well Construction - GW1_20210527

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
i
Frankie L.Oliver 14.WATER ZONES"- "
FROM TO DESCRIPTION
Well Contractor Name
90 ft. 473 fc.
3002-A rt n
480
NC Well Contractor Certification Number '15.OUTER CASING(for multi-cased'wells)OR LINER if a licabie
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATF,RIAI.
0 ft. 50 ff 61/8 1n' I SDR21 PVC
Company Name ,16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 20-532 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. r, in.
3.Well Use(check well use): fL ft. in.
Water Supply Well: 17.SCREEN
PP Y FROM TO DIAMETER SLOT SI7% THICKNESS MATERIAI.
Agricultural rIMunicipaVPublic O ft. It. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) IS.GROUT '
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 20+ ft' Bentonite Pour 14 50Ib Bags
Monitoring ORecovery et fL
Injection Well:
ft. ft.
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL.PACK(If a livable), <-+,
Aquifer Storage and Recovery OSaliniry Barrier FROM To MATERIAL EMPI,ACF.MENT METHOD
Aquifer Test OStormwater Drainage ft. fL
Experimental Technology OSubsidence Control
Geothermal(Closed Loop) Tracer Z0:DRILLING LOG,,attach,additiobal sheets if necessary)
Geothermal(Heating/Cooling/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soittrock type, rain size,etc.)
0 ft' 6 ft' Red Clay
4.Date Well(s)Completed: 4-29-2021 Well ED# 6 ft' 20 ft. Brown Dirt/Rock
5a.Well Location: 20 ft' 500 It. Blue Slate
Daniel Crook ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft' ft'
1702 Mill Creek Church Rd. Monroe 28110 Goose Creek#2 ft. ft
Physical Address,City,and Zip
ft. ft. @ a�
Union 08-102-005K 21 REMARKS . "
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: r' n
VVt�
(if well field,one lat/long is sufficient) 22.Certification:
35.40.300 N 80.29.064 W ( d0411 Agg�:>
5-17-2021
6.Is(are)the well(s) Permanent or OTemporary Signature of Certified Well Contractor Date
By signing this fonn,I hereby certify that the tvell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or RNo with ISA NCAC 02C.0100 or 15A NCAC 02C.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 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: 500 (fl-
P ) 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 2@I00') construction to the following:
10.Static water level below top of casing: 29 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above caving,tcse"+ 1617 Mail Service Cc i nter,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.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) 3 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: 30oZ completion of well construction to the county health department of the county
where constructed.
Fortin GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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