GW1-2021-02694_Well Construction - GW1_20210527

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver ;14.WATERZONES-
FROM TO DESCRIPTION
Well Contractor Name
128 ft. ft.
3002-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi•eased wells)OR LINER[f a cable),
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 fL 47 fL 6 1/8",I" I SDR21 I PVC
20-579 16.INNER CASING OR TUBING' eothermal dosed-too
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) fL ft. in.
3.Well Use(check well use): fL ft in.
Water Supply Well: SCREEN � .:;.
FROM TO DIAMETER SLOTSIZE THICKNESS I MATERIAL
Agricultural []Municipal/Public ft. fL in.
Geothermal(Heating/Cooling Supply) Wesidential Water Supply(single) fL fL in,
Industrial/Commercial Residential Water Supply(shared) s_.18:GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 20+ fL Bentonite Pour 13 501b Bags
Monitoring ORecovery ft. ft.
Injection Well:
fL fL
Aquifer Recharge OGroundwattr Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL, EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. fL
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20:DRILLING LOG"attach additional sheets if necessar
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiltrack type, in sin,etc.)
0 fL 10 ft, Red Clay
4.Date Well(s)Completed: 4-30-2021 Well ID# 10 fL 26 fL Brown.Dirt/Rock
Sa.Well Location: 26 ft' 200 ft- Granite
David&Ashley Jolley ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft, ft. rn
�.�
7914 Haigler Gin Rd. Monroe 28110 fL fL "_
Physical Address.City,and Zip ft ft. 7 20
21
Union 08-015-001 G :21.REMARKS
ry �� SSICt
County Parcel identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.60.843 N 80.25.954 W
�� 5-21-2021
6.Is(are)the well(s) Permanent or OTemporary Signature of Certified Well Contractor Date
By signing this form, 1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or [?No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Slumlords 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 well1details:
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-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: 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 2@1001 construction to the following:
10.Static water level below top of casing: 17 Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+' 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 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) 16 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.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources i Revised 2-22-2016
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