GW1-2022-03704_Well Construction - GW1_20220330

WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver 14 WATEW"",7,0N !,
FROM TO I I DESCRIPTION
Well Contactor Name
77,82 tr• 86,92 tt.
3002-A
98,112tt' 1251 tL 132.171J89
NC Well Contractor Certification Number t',1&:0UTER:GASING'iar,niulti-iik§M:wefs,OR:LINER;If e' Hcable,.rr
Carolina Well Drilling FROM TO I DIAMETER THICKNESS MATERIAL
0 tf 73 ft- 61/4 In. SDR21 PVC
Company Name
?;Y6 INNER CA'S1NG OR•TUBING eGtherinel dosed laa v'
2,Well Construction Permit#: 21-243 FROM I TO f DIAMETER I THICKNESS MATERIAL.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. fL in.
3.Well Use(check well use): ft. ft- in
t 17:°SCREEN.._,`'`" �
Water Supply Well: FROM TO DIAMETER K SLOT SIZE THICKNESS MATERIAL
Agricultural [:)MunicipaVPublic fL I ft. In.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ty 't1-
Industrial/Commercial 13Residential Water Supply(shared) I8 GROUT P1
irri ation FROM TO MATERIAL, EMPLACEMENT METHOD&AMOUNT`
Non-Water Supply Well: 0 t`' 20 tL Bentonite Pour 35 501b Bags
Monitoring 13Recovery tL ft.
Injection Well: 56L
Aquifer Recharge Groundwater Remediation
R'Ay 'PACK i[a IlcableAquifer Storage and Recovery [3Saliniry Barrier TO MATERIAL. EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage rL
Experimental Technology Subsidence ControlGeothermal(Closed Loop) TracerING,L0 :attach addiddnlGeothermal(Heatin Coolin Retum) Other ex lain under#21 Remarks TO DESCRIPTION color hardness solVrock t rain sim eta)
6 i fLRed Cla4.Date Well(s)Completed:2-24-2022 Well ID# 31' tLOran a/Red Dirt
So.Well Location: 56tf B I oJames Caudill 206 fL Granite
Facility/Owner Name Facility rD#(if applicable) O' 1 H'
395 Pinewood Ln.Midland 28107 ft. ft.
Physical Address.City.and Zip ft. I ft.
Cabe rrus 55249424660000 -11tiXEMARKS i:= �
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IatAong is sufficient) 22.Certification:
35,14.067 N 80.34,616 W v, °� •� v�f .� 3-23-2022
6.Ls(are)the well(s)OPermanent or Temporary Signature of Certified Wen Contractor
By signing this(orm,11 hereby certiiA-that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or W No with 15A NCAC 02C.`0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If ilnis is a repair,fill nut knomm well construction information and explain the nature of ilie copy of this record has been provided to the well oit ner.
repair under#21 remarks section or on the hack of this fors 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loup Geothermal Wells having the same You may use the buck 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: 200 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For niuhiple wells list all depths ifdifjerem(example-3@200'and 2@100') construction to the following:
i
10.Static water level below top of casing: 51 (ft-) Division bf Water Resources,Infonnutiun Processing Unit,
If water level is above casing,use"+" 1617 t ail Servtcc Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection 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) 28 Method of test: Air 24c.For Water SUDDly&Iniection Wells: In addition to sending the form to
the address(es) ab ve, th also submit'one copy of this for within 30 days of
13b.Disinfection type: 70%HTH Amount: 12o2 completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division oP Water Resources Revised 2-22-20I6
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