GW1-2022-08470_Well Construction - GW1_20220426

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver 44.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
169 ft' 265 ft.
3002-A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER.(if a `livable)
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. ft.45 61/4a in. I SDR21 PVC
22-55 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#' FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pennits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. rn•
Water Supply Well: 17.:SCREEN
pp y FROM TO DIAMETER .SLOT SIZE THICKNESS MATERIAL
__ Agricultural DMunicipalftblic ft. ft. in.
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) fa ft.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 20+ ft' Bentonite Pour 16)501b Bags
Monitoring E3Rccovcry ft. ft.
Injection Well:
ft. et.
Aquifer Recharge OGroundwater Remediation
49.SAND/GRAVEL:PACK(if applicable)_
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage
Experimental Technology rl Subsidence Control
Geothermal(Closed Loop) EITracer 20.DRILLING LOG(attach additional sheets if necessary
FROM TO DESCRIPTION(color,hardness,soillrock type,grain size,etc.)
Geothermal(Heating/Cooling Return) MOther(explain under#21 Remarks)
0 ft. 3 et. Brown sandclay
4.Date Well(s)Completed:3-14-2022 Well ED# 3 ft' 38 ft- Brown Clay/Rock
5a.Well Location: 38 ft. 275 ft' Granite
Larry Myers ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. r,
2016 Ruben Rd. Monroe 28112 ft. ft.
Physical Address,City,and Zip
Union 04-231-001 B 21:RE1bIARKs A^ t Ep;:.
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:
34.52.441 N 80.35.547 W
4-7-2022
6.Is(are)the well(s)&Permanent or OTemporary Signature of Certified Well Contractor Date
By signing this form, I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [DYes or RNo 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 information 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 forvn.
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: 275 V0 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100D construction to the following:
10.Static water level below top of casing: 15 (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 Injection 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) 75 Method of test: Air 24c.For Water Supply&Iniection Wells: In addition to sending the forni to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 70% HTH Amount: 18oz 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