GW1-2022-07568_Well Construction - GW1_20220815

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WELL CONSTRUCTION RECORD (GW-1) For Internal Usr Only:
1.Well Contractor Tnforination: j
r
Frankie L.Oliver :14SV
Well Contramr Name FROM I TO DESCRn"RON
3002-A 95,97 ft 104, ft.
113 ft. 1 ft. 163 170 232 396 412
NC Well Contractor Certification Number 5.t)11 NRfi�AS Ct f i tr� tii•" da #i ?p121iiNFlt(1fs icabtb';., xc xT A,r
Carolina Well Drilling FROM TO; DIAMETM THICKNESS MATF.R 4L
Company Name 0 ft' 84 ft. 61/4 In' SDR21 PVC
22-212 ,`tc dl......tt" A. .� �' 1NG' � Fire ail <� y��� �...ye" �
2.Well Construction Permit 4: FROM TO DIAMETI2t THICKNESS MATERIAL.
List all applicable well consnucnon prrrrrirs(i.e.111C,County,State,Variance,etc.) ft• ft. tn.
3.Well Use(check well use): It. it. In.
Water Supply Well: r"t7,"S�REN,N
FROM I TO I DIAMF'r6R I SLOT SIZE TFRCKNPSS I MATF.RTAI
Agricultural ®MunicipaVPublic fL ft. En:'
Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ft. ft, in.
IndustriaUCommercial ®Residential Water Supply(shared)
Irrigation FROM I TO MATERIAL F.AML.ACF.MIM METHOD&AMOUNT
Non-Water Supply Well: 0 ft.
2 + n' Bentonite Pour 38 501b Bags
Monitoring 1311ccovery
Tnjection Well: et. ft.
Aquifer Recharge ®Groundwater Remediation
9 l�Pifi%(41f' .SaT`.'Ca[C#((P`n `"li�tiilr'.1 �` �"�.W� ••tea?
Aquifer Storage and Recovery ®Salinity Barrier FROM To MATERIAL EMN ALF39ENT METHOD
Aquifer Test [3Stormwatet•Drainage
ft. ft.
Experimental Technology ®Subsidence Control ft. ft.
Geothermal(Closed Loop) ®Tracer '";ltl:'t RILIi11!(G„ ( tilditiiii(gi4FsE,ti€1
Geothermal eatin /Coolie Return Other ez lain under 421 Remarks FROM TO nFSCRTPTION color,hardn solltroek rain sou etc
0 ft 3; ft' Red Clay
4.Date Well(s)Completed: 7-22-22 Well ID# Well#3 37 n 75 ft' Brown ShalelftqVl
Sa.Well Location: 75 450 ft. Granite
Circle S Ranch ft ft.
Facility/Owner Name Facility M#(if applicable) f49
Austin Rd. Monroe 28112 mLl u ;BOG
!
Physical Address,City,and Zip ft. ft.
Union
04-213-010 21 Msfi5>, T^ _, .z ,r� :� . •, , .
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degreeshninutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certirteatio n:
34.50.147 N 80.33.432 W 7-27-22
6.Is(are)the wells)f0Permanent or 13Temporary Signature of Catised Well Contractor Date
By signing This fo i I hereby certify Thar the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or JoNo with 15A NCAC O�C.0100 or 15A NCAC 02C.0200 Well Conspuction Standards and that a
lfthis is a repair,fill nut known well cnnstructinu info rmatirm aril explain the nature of the copy of this record hat been provided to the well owner.
repair tinder#21 remarks section or on the back of this form. 23.Site diagraT7 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 dowils or well
construction,only I GW-i is needed. Indicate TOTAL NUMBER of wells construction deu its. You may also attach additional pages if necessary.
drilled: U iiiiii CIO S
9.Total well depth below land surface: 450 oft.) 24a. For All ells: Submit this form within 30 days of completion of well
Fnr multiple welds fur all depths if different(e_%anple-3Wf111'and 2@1001 construction to I e following:
10.Static water level below top of casing: 47 (ft-) Division of Water Resources,Information Processing Unit,
If water tcvcl is above casing,use"+" I Ii17 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in-) 24b.For Ittlec on Wells: In addition to sending the form to the address in 24a
Air Rotary above,also sub nit one copy of this form within 30 days of completion of well
12.Well construction method: construction to a following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources;Underground Tnjection Control Program,
FOR WATER SUPPLY WELLS ONLY: t�i36 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 18 Method of test: Air 24c.For Wate•Supply&Injection Wells: In addition to sending the form to
the address(es) above, also subinit one copy of this form within 30 days of
13b.Disinfection type: 70%HTH Ap t. 30oZ completion of well construction to the county health department of the county
where constructerd.
I
Form GW-I North Carolina Department of Environmental Quality-Divisi n of Water Resources Revised 2-22-2016