GW1-2022-07569_Well Construction - GW1_20220815

WELL CONSTRUCTION RECORD (GW-1) For Internal Ube Only:
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1.Well Contractor Information:
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Frankie L.Oliver
Well Contractor Name pttohf TO DFSCitIPTION
3002-A 114 ft. 121 ft-
131 ft. 285 ft' 350 4
NC Well Convector Certification Number 5,e :[1TFRwtat ti"'4rvinulttvi will'`ells Oti l TNFit`iYii" tiCabl2' e av_<' n
Carolina Well Drilling FROM TO` I DIAMETER THICKNESS MATERIAL
Company Name 0 it. 10 f' 61/4 i"' SDR21 PVC F
:,f16; _ R .rtR .ilslric ,, ilicriiifili •taI <�;n"
2.Well Construction Permit#: 22-214 FROM TO' I DIAMETER I TMCKNFSS MATERIAL
List all applicable ivell construction pemits(i.e.U1C,County,State,Variance,etc.) ft. ft. In.
3.Well Use(check well use): ft. ft, in.
Water Supply Well: FROM TO z DIAMrrFR I SLOT SIZE I TRTCRNRSS I MATF.RTAT,
Agricultural ®Municipal/Public ft. M
Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single)
Industrial/Commercial DResidential Water Supply(shared) y• �' rs .' „° F °, .
Irrigation FROM I TO MATERIAL EMt°i.ACEM]Wr METHOD&AMOUNT
Non-Water Supply Well: 0 f' 20,+ f' Bentonite Pour 45.5 501b Bags
Monitoring 13Recovery ft. ft.
injection Well: ft n
Aquifer Recharge ®Groundwater Remediation
`� ,'•€:i� w'
Aquifer Storage and Recovery [3Sahnity Barrier FROM TO f MATERIAL EMPLAt EXENIT METHOD
Aquifer Test ®StormwaterDrainage ft. ft.
Experimental Technology oSubsidence Control ft. ft.
Geothermal(Closed Loop) ®Tracer As -- ttfo k>~
Geothermal(Heating/Cooling Return) Other(explain under 4121 Remarks FROMI TO DFACRTPTiON color,hardness soll/roek tyM grain sire eta
0 f' 63 ft' Red Clay
4.Date Well(s)Completed: 7-13-22 Well IDii Well#1 63 ct. 91` f' Brown Shale
Sa.Well Location: 91 ft. 600 ` Granite
Circle S Ranch Pt. n.
Facility/(Tuner Name Facility ID#(if applicable) _^-
Austin Rd. Monroe 28112 i3. { n. .
Physical Address,City,and Zip
Union 04-213-010 z sR ttitAxx a< : �:: r
rJs"#�:u 300
Cowry Farrel Identification No.(PIN)
5b.Latitude and longitude In degrees/inlnutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.Certification:
34.50.102 N 80.33.436 `1t ! �y..�
7-27-22
Permanent of Tent otar rgtattne of Certified Well Contractor Date
w 6.Is(are)the ells) P y
By signing this joint;I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or 5JNo with 15A NCAC 02CL0100 or 15A NCAC 02C.0200 Welt Coosrmclion Standards and that a
1f this is a repair,fill our kn emn it-ell construction information and explain the nature of the copy of this record hr been pmvided to the well owner.
repair tinder#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 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 will depth below land surface: 600 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
Fur multiple iveliv list all depths if different(ex urine-3@200'and 2@100) construction to the,following:
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10.Static water level below top of casing: 52 (ft) Division of Water Resources,Information Processing Unit,
If inter level is above casing,rise"+" 161 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For In ectlo Wells: In addition to sending the forth to the address in 24a
Air Rotary above,also subi k one copy of this form within 30 days of completion of well
12.Wellconstxuctlon method: construction to the following:
(i.e.auger,rutary,cable,direct push,etc.) I``
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 163 i Mail Service C I:enter,Raleigh,NC 27699-1636
13a.Yield(gpm) 18 Method of test: err 24c.For Water. unvlv&r Wection Wells: In addition to sending the form to
the address(es) it ocive, also submit one copy of this form within 30 days of
13b.Disinfection type: 70%HTH Amount. 30oz completion of wt:1 construction to the county health deparanent of the county
where constructed
Form GW-1 North Carolina Department of Environmental Quality-Division f Water Resources Revised 2-22.2016