GW1-2022-08438_Well Construction - GW1_20220426

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver 14.WATER ZONES,
FROM TO DESCRIPTION
Well Contractor Name
3002-A 75 f`' 108
115 f`' 137 f` 158
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OIL
R LINER(if a livable
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft 62 f`' 6 1/4" '"' SDR21 PVC
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 21-177 5FROM
TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIC,County,State,Variance,etc.) ft. in.
3.Well Use(check well use): ft. in.
Water Supply Well: EN,`-
TO DIAMETER SLOTSI7.E THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)Industrial/Commercial Residential Water Supply(shared) T
Irri ation TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 • 20+ f`' Bentonite Pour(22)501b Bags
Monitoring DRecovery
Injection Well:
ft. ft.
Aquifer Recharge EIGroundwater Remediation
19.SAND/GRAVELPACK if applicable),
Aquifer Storage and Recovery [3Saliniry Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage
- Experimental Technology OSubsidence Control
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
'Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiltrock type, rain size etc.)
0 f`• 14 fL Brown Clay
4.Date Wells)Completed:3-29-2022 Well ID# 14 f`' 18 ft' Brown Shale
5a.Well Location: 18 ft. 175 f`' Granite
Kay Gould ft et.
Facility/Owner Name Facility ID#(if applicable) ft. ft. 022
7316 Tesh Rd.Monroe 28110 ft. ft.
Physical Address,City,and Zip ft. ft. ( ' 1
Union 08-153-014 z1,REnIARxs , r
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.70.865 N 80.31.028 W
4-7-2022
6.Is(are)the well(s)&Permanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the tvell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYeS or E?No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction 6 fonnation and explain the nature of the copy of this record has been provided to the well owner.
repair under#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 well depth below land surface: 175 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 33 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection 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) 35 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: 12oZ 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