GW1-2022-07572_Well Construction - GW1_20220815

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L. Oliver i 14.WATER ZONES
Well Contractor Narne FROM TO DESCRIPTION
131 ft. 136 ft.
3002-A
19.9 ft' 373 et' 491505
NC Well Contractor Certification Number .15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Carolina Well Drilling FROM I TO I DIAMETER TIUCKNESS 9MATERUL
Company Name
0 ft' 76 ft 61/4 in' SDR21 PVC
22-112 16.INNER CASING OR TUBING,( eothermal dosed-loop)
2.Well Construction Permit#: FROM TO DIAMETER TMCKNFSS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use):
17,SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATF.RIAI,
Agricultural nMunicipal/Public fy tt is
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Indusvial/Commercial Residential Water Supply(shared) GROUT
_ Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20+ ft Bentonite Pour 23.5)501b Bags
Monitoring 13Recovery ft ft.
Injection Well:
Aquifer Recharge Groundwater Remediation 19:SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery []Salinity Barrier FROM TO M.ATERLAL EMPI ALEMENT METHOD
Aquifer Test [)Stormwater Drainage
ft. ft.
Experimental Technology ®Subsidence Control ft. ft.
Geothermal("Closed Loop) ®Tracer 20.DRILLING LOG iattach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under 421 Remarks) FROM TO DFSCRTPTION(color,hardness sotl/rock type,grain size etc)
0 ft. 8 rt. Brown Clay
4.Date Well(s)Completed: 6-6-22 Well ID# 8 ft. 550 ft. Blue Slate
52.Well Location: ft. ft.
Jason McBride ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft
503 Stack Rd. Monroe 28112 ft. ft A U f I ; 2022
Physical Address,City,and Zip
ft. ft.
Union 09-207-050A -
vta r
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degreeshninutes/seconds or decimal degrees:
(if well field,one la/long is sufficient) 22.Certification:
34.93.359 N 80.53.246 W
7-5-22
6.Is(are)the well(s)OPermanent or OTcmporary Sijr7i5c of Certified Well Contractor Date
Ay signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an eidsting well: ®Yes or 53No with 15A NCAC 02C.0100 or 15A NCAC;02C.0200 Well Construction Standards and that a
If this iv a repair,fill out kiwim well construction information and explain the nature of the copy of thiv record hat been provided to the well owner.
repair under#21 remarks section or on the back of this farm.
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 well depth below land surface: 550 ML) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells lia all depthv if different(example-3g200'and 2(a 700� construction to the following:
1.0.Static water level below top of casing: 35 ([t) Division of Water Resources,Information Processing Unit,
If water level is above rasing,use"+" 1617 Mail Service 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) 30 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: 32oZ 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 Revised 2-22-2016