GW1-2022-08485_Well Construction - GW1_20220426

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver `A4.,WATER=Z6NES
FROM TO DESCRIPTION
Well Contractor Name 384 ft, 408 fL
3002-A 533 ft. 563 fL 585,699,724,748
NC Well Contractor Certification Number
15 01J1 ER"CASING(for itul8•cased.wells)OR LINER(if a hcable).`
Carolina Well Drilling FROM fL TO ft DIAMETER in. THICKNESS MATERIAL
0 48 61/4 SDR21 PVC
Company Name 16 INNER CASING OR.TUBING(eothernm. 09ed loo )
21-411 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft.
ft. DIAMETER
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)
ft. fL in.
3.Well Use(check well use):
Water Supply Well: FROM
SCREEN
FROM TO "- DIAMETER -SLOT SIZE THICKNESS MATERIAL
Agricultural [3Munieipal/Public fa ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft it. in.
Industrial/Commercial Residential Water Supply(shared) 18:�GROUT.. �w, '-- •- °`
L77 a[lOn FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 20+ fL Bentonite Pour(14)501b Bags
Monitoring Recovery ft. fL
Injection Well: ft. fL
Aquifer Recharge [3Groundwater Remediation
�19.SANDlGRAVEL PACI{'(if a licalile)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test oStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 1:�X'DRILLING:LOG attach additional shcetsif tiecessar
RGeothermal
FROM TO DESCRIPTION(color hardness,soitlm&tye,-ram snc,etc.)
(Heating/Conlin Return) Other(explain under#21 Remarks)
0 ft. 5 fL Red Clay
4.Date Wells)Completed:2-18-2022 Well ID# 5 M 17 f' Brown Dirt
5a.Well Location: 17 ft' 33 ft' Brown Shale
Katie Ryals 33 ff' 775 ft- Granite.
Facility/Owner Name Facility ID#(if applicable) ft. ft. WIT Pot _
Willoughby Woods Dr. Monroe 28110 The Farms of Willoughby ft. ft.
«l
ft. fL
Physical Address.City.and Zip
Union 09-348-200 21:REMARKS
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:
34.59.334 N 80.35.854 W
3-8-2022
6.Is(are)the well(s)oPermanent or OTemporary Signature of Certified Well Contractor Date
By signing this fonn, I hereby certify that the tvell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes 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 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 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: 775 (ft-) 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@100) construction to the following:
10.Static water level below top of casing: 25 (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) 18 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: 42oZ completion of well construction to the county health department of the county
where constructed.
Forni GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016