GW1-2022-07566_Well Construction - GW1_20220815

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information:
Frankle L.Oliver 14 41V. It'zo ,t t �, a aLf}
Well Contractor Name FROM TO DESCRIPTION
49,55 ft- 58,61 ft'
3002-A 08 ft 130 ft' 189 249
NC Well Contractor Certification Number 1 1 ?G13 Gl ti t15i11ti- '�'A`i�eOs;ORsiXNFk`It a i�iiiE `,h�� '<° ?r
Carolina Well Drilling FROM TO i DIAMETER THICKNESS MATERIAL
Company Name 0 ft- 45 ft. 61/4 1n' SDR21 PVC
r.9NNl&Rt(vA .. 11 .°R° ,i1DING;' ( tir°Irr8I1; clbo :'> _;• '
`s
2.Well Construction Permit#: 22-219 FROM TO DIAMETER I nUCIWFSS I MATERIAL
List all applicable well cansdnction prtmits(i.e.U1C,Cowv,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. In.
Water Supply Well:
19`;tGR1E a `� 7 e` tF
FROM TO lI n1AMFTFR fI SLOTSIZE I TMCKNFSS I MATF.RTAT
Agricultural ®MtmicipaUftblic ft. ft. in.!
Geothermal(Heating/Cooling Supply) lWesidential Water Supply(single.) � in.
Industrial/Commercial 13Residential Water Supply(shared) - e
g1ii�RU
Irri ation FROM TO MATERIAL EM11LACFM1Nr METHOD&AMOUNT
Non-Water Supply Well: 0 f 204:1 ft' I Benton'ite Pour 12 501b Bags
Monitoring DRecovery
injection Well:
Aquifer Recharge ®Groundwater Remediation
.�3r;SA.D/(�111A4�t xiji\'�K('fifi• •llt�iit/1e� t�:5„`..8�r,:. .✓ :': era.:^ s
Aquifer Storage and Recovery ®Salinity Barrier FROM I TO MATERIAL EMPLA(MMENT METHIID
Aquifer Test 0Stormwater Drainage rL
Experimental Technology Subsidence Control
Geothermal(Closed Loop) 13Tracer xAi3D i311ING>L°'Of litfilcliddiilfir,itl'sheefslfilfeessa
Geothermal(Heatin C oling Return) Other(explain under#21 Remarks FROM To I I DFSCRTPTTON color,hardnM solUrock type,grain air etc.)
0 ft. 9 ; ft. IBrown Clay/Shale
4.Date Well(s)Completed: 6-16-22 Well HM 9 ft' 265 ft' Blue Slate *R-
So.Well Location: ft. ft. �e
Kathy Benton rt. ` ft.
Facility/Owner Name Facility Ill@(it applicable) ft. f
t.
2113 Village Ln.Monroe 28110 Candlewood Village Lot#8 et. it. i��r ;;cl Urt�
Physical Address,City,and Zip rt. ; ft. ✓°' 1
Union
09-075-021 z1REtu R1G.,•;TU7777
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/ndnutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: i
35.10.385 N 80.29.704 `,i, �
�1� 6-29-22
6.Is(are)the wells)JOPermanent or Temporary Signattrrc of Certified Well Contractor Date
By signing Ibis form 1.hereby cenifp that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or Sallo with 15A NCAC 02C.t)100 or 15A NCAC 02C.0200 Well Construction Standardr and that a
If this it a repair,fill our knrmn well conrrructinn irlformalinn and explain the nature of the copy of ihlr rrcmd hnr,heen provided to rise well nxmer.
repair under#21 remarks section or on the bark 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 udditiunal well site details or well
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells construction details 1 You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 265 00 24a,. For All W 11 : Submit this'fonn within 30 days of completion of well
For multiple rvelb lire all depths ifdi ferent(eumrle-3g200'and 2W 001 construction to the following:
10.Static water level below top of casing: 1 00 Division Of Water Resources,Information Processing Unit,
)f water level is above rasing.use"+" 1617 ail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in-) 24b.For trilection 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 thefollowing:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Wal jer Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636lMail Service Center,Raleigh,NC 27699-1636
139.Yield(gpm) 40 Method of test: Air 24c or Water S IIumly&In'ectitm Wells: In addition to sending the form to
the address(es) ab ve, also submit one copy of this form within 30 days of
13b.Disinfection type: 70%HTH Amount -1 6oZ completion of wet construction toithe county health department of the county
where constructed.i
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Recourme ? Revised 2-22-2016
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