GW1-2022-09205_Well Construction - GW1_20220930

WELL CONSTRUCTION RECORD (GW-1) For Internal UseOnly:
1.Well Contractor Information:
Frankie L.Oliver t4v-A RlZO t u t �fr7<, F.;fir
FROM TO i DESCRII'TiON
Well.Cuntrautur Name
47 ft. 73 ' n.
3002-A
97 ec. 149 rt.
NC Well Contractor Certification Number 4)t5%b11T1ttilrSlN iffr611u1{f4scBtIls"aft°I1 1t .:a It;�Yb e
Carolina Well Drilling FROM To DIAMETER TMENIE's MATERIAL.
mpa CuuyName 0 et. 44 n' 61/4 i"' SDR21 PVC
;FROM
2.Well Construction Permit#: 22-281 TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction petmils(i.e.WC.Courtly,State,Variance,etc.) fl.3.Well Use(check well use): n. tn.
ater Supply Well: TO I DiAMFTFR SI OTS17F THICKNPSS MATP.RTAAgricultural ®Mumcipal/Public In. in.
Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) t.Industrial/Commercial ®Residential Water Supply(shared)hri atiun TO MATERIAL EM1`1 ACEMENT METHOD AMOUNT
Non-Water Supply Well: 0 n' 20+ n' Bentonite Pour 14 501b Bags
Monitoring Recovery ft. ft.
injection Well: ft ft
Aquifer Recharge ®Groundwater Remediation
iA19;5•'Nb/(IpA Y+�1!A�ae r� lrflitll °. .. ,�i s.x � y:�k,
Aquifer Storage and Recovery Salinity Barrier FR11M To MATERIAL EMPLACEMEANT METHt1D
Aquifer Test QStonnwater Drainage rt. n.
Experimental Technology Subsidence Control n. it.
Geothermal(Closed Loop) ®Tracer +ftlrbRIliT,iNOGf ttti 'd8116ttii Bhekti[3iaieke '. `"H 4 ':""
Geothermal eating/Coolie Return) Other(explain under#21 Remarks FROM To DFSCRTPTTON color,hardness aotl/reck type,Araln stre etc
0 ft' 8 ft' Brown Dirt/Shale
4.Date Well(s)Completed: 8-26-22 Well ID# 8 n' 200 n' Blue Slate
n. n.
Sa.Well Location:
Sybil Noble rt. n.
Facility/Owner Name Facility IDN(if applicable) O.
5507 Pleasant Hill Church Rd. Marshville 28103 ;• - i, _'B. '
rt. ft.
Physical Address,City,and Zip
Union 01-066-011 B1� t
County I'arml Identification No.(PIN) -: Unii
5b.Latitude and longitude in degreeshninutes/seconds or decimal degrees: OG
(if well field,one tatllong is sufficient) 22.Certification:
35.60.281 N 80.17.556 W � �
9-19-22
6.IS(are)the well(s)JOPermanent or Temporary Signattue of Certified Well Contractor Date
Bi•signing this form.I hereby certify Am the well(j)was(were)corutrucled in accordance
7.Is this a repair to an existing well: ®Yea or Jallo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this it a repair,fill out known well cmarructinn infnrmatinn and explain the nature of the copy of this record her been provided to!the well onwer.
repair tinder#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 16 provide additional well site details or well
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also!anach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 200 (it.) 24a. For All Wells: Submit this form within 30 days of completion of well
Fnrmulunle ivellt licratll depths((different(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: 33 (ft.) Division of Water Resources,Information Processing Unit,
1f water level is above casing,use-+- 16/7 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 subtftit 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 posh,etc.)
Division of Water Resources,iUnderground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 8 Method of test- Air 24c.For Water Supply&Injection Wells: In addition to sending the form to
the addresses)!above, also submit one copy of this form within 30 days of
13b.Disinfection type: 70%HTH Amount: 12o2 completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Divisign of Water Ruources Revised 2-22-2016