GW1-2022-09202_Well Construction - GW1_20220930

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
i
Frankie L. Oliver 14.WATER ZONES Well Contractor Narne FROM TO DESCRH-TION
130 ft' 140 ft.
3002-A
ft. «. '
NC Well Contractor Certification Number
15.OUTER EASING(Farinulti-cased wells)OR I.iNFR if a livable)
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name
0 ft' 60 «' 1 6 114 i in.
SDR21 PVC
U1iINf,
22-1 O1 16.INNER CASING nR.T ( er(therrnal closed-loop),, : ,
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
il"Irrigation
ater Supply Well:
FROM TO DIAMETER SLOT SUE THICKNESS MATF.RiAi.
Agricultural ©Mimicipal/Public ft• rL in.
Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ft. ft. in.
htdusuial/Cominercial 13Residendal Water Supply(shared)
1R:GROUT
FROM TO MATFRrAr EMI-LACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20+ ft. Bentonite Pour(12)501b Bags
Monitoring C3Recovery ft. ft.
injection Well: ft. ft.
:-)Aquifer Recharge 13Groundwater Remediation 19.SAND/GRAVF.T,PACK(if a licable)
Aquifer Storage and Recovery 13Salinity Barrier FROM TO I MATERIAL I EMPLACEMENT METHOD
Aquifer Test []Stonmwater Drainage ft. ft.
Experimental Technology OI Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheetS if ne(!essary)
FROM TO DFSCRTPTION(color,hardness setl/rock rain slue etc)
Geothernal(Heatin /Conlin Return) ,Other(explain under#21 Remarks)
0 ft. 25 ft, Red Clay
4.Date Wells)Completed: 7-12-22 Well ID# 25 ft. 100 ft. Brown Shale/Granite/Gravel
Sa.Well Location: 100 ft. 580 ft• Granite
Kevin Powell ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. ( 7
640 Winter Wheat Ct.Weddington 28104 Atherton#60
Physical Address,City,and Zip ft. ft. _ i. 0 207
Union 06-233-23 21.REMARICS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/niinutes/seconds or decimal degrees: *Sand seam at 76,85
(if well field,one lat/long is sufficient) 22.Certification:
35,14.250 N 80.43.118 W
7-12-22
6.Is(are)the well(s)OPermanent or OJ Temporary Signature of Certified Well Contractor Date
Br signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or Sallo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
if this is a repair,fill our bison well cnrstructinn information and explain the nature of the copy of this reenid has been provided to the well naner.
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 wel l
construction,only I GW-I 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: 580 Jt-) 24a. For All Wells: Submit this form within 30 days of completion of well
Fnr multiple wells list all depths ifd f{erent(extunple-3g2110'and 2@100� construction to the following:
10.Static water level below top of casing: 35 (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 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,direr[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) 2 Method of test: Air 24c.For Water Supply&Injection 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: 48oZ completion of well construction to the county health department of the county
where constructed.
Forrn GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016