GW1-2022-09207_Well Construction - GW1_20220930

WELL CONSTRUCTION RECORD (GW-L) For Internal Upe Only:
1.Well Contractor information:
775��_
Frankie L.Oliver X1414VATM. ��Vk7,4 I W
1* . A
FROM TO DESCRIKION
Well,Curitnictur Name 48,62 6995 ft' I
3002-A 102fL 11 ft. 137 1
NC Well Contractor Certification Number
Carolina Well Drilling FROM TO I DIAMETER THICKNESS MATERIAL
0 Ft. 44 ft.
6 1/4 In' SDR21 PVC
Company Name In
2.Well Construction Permit#: 22-152 FROM ft. TO ft. DIAMETER In. IMCKNESS I MATEPJAL
List all applicable well conmuction pennits(i.e.UIC,County,State,Variance,etc.)
3.Well Use(check well use)-
r ft. R. In.
F Water Supply Well: FROM TO THAM"" I SLOT ST7,r 1 TIFICRNITM MATRRIAt,
Agricultural 13Municipal/Ptiblic ft. ft. In.
Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ft. ft. in.
Industrial./Commercial 13Residential Water Supply(shared) t48-tGROU1 r6
ItTigation FROM TO MATERIAL EAGIACEMENT MXTHOD&AMOUNT
Non-Water Supply Well: 0 26+ ft' Benton ite Pour(20)501b Bags
3Monitoring 13Recovery ft.
Trijection Well:
ft. ft.
3Aquifer Recharge ®Groundwater Remeditition
21490900/41R,_ ll, I V
lAquifer Storage and Recovery ®Salinity Barrier FROM NL4,TERL4,L I I EM PL4,CEMENT METHt nD
Aquifer Test [3stortriwater Drainage
Experimental Technology 13Subsidence Control
Geothermal(Closed Loop) ®Tracer
Geothermal(Heating/Cooling Return) r3 Other(explain under*21 Remarks) FROM TO I TITSCUTPTION(color hardness,solltrock type,Amin slit,etc.)
0 ft. 24 ft* Brown ClayjRock
4.Date Well(s)Completed: 9-8-22 Well M# 24 f" 200 ft* Granit;e
59.Well Location: ft. ft.
Lucas Braswell
Facility/Owner Name Facility TD#(if applicable) ft. S I-P 3
610 Bruce Thomas Rd.Monroe 28112 ft. ft.
.
Physical Address,City,and Zip ft. ft
2
Uri
Union 04-117-011 J
County Parcel Identification No.(PIN)
5b.Latitude and longitude In degrees/mInutes/seconds or decimal degrees:
(if well field,one la(/long is sufficient) 22.Certiflcationd
34.53.541 N 80.30.536 W 9-19-22
6.Islam)the well(s)OPermarieut or OTemporary Signature of Certified Well Contractor Date
By signing this forni,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an eidsting well: ®Yes or Eallo with 15A NCAC 02d.0100 or 75A NCAC 02C.0200 Well Cownuction Standank and that a
If this is a repair,fill ou;krzown well conirmction itiforinatinn and explain the nature of the cnpy of this reenrd haw been provided in the well nearer.
repair under#21 remarks section or on the back of this form. 23.Site dingrambr additional will details:
8.For Geoprobc/DPT or Closed-Loop Geothermal Wells having the same You may use the lback of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
construction,only I GW-I is needed. Indicate TOTAL NUMBER of well., i
drilled: susmrrm INSTRUCTIONS
9.Total well depth below land surface: 200
(ft') 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells lia all depths iftlifferehi(exiunple-3@200'and 2@1001 construction to thi following:
10.Static water level below top of casing: 26 (ft.) Division of Water Reso"orces,Information Processing Unit,
If water level is above casing.use 11611i7 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Lidectioln 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
11 Well construction method: construction to th�following:
(i.e.auger,rutury,cable,direct push,etc.) Division of W I pter Resources,i Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1616 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)_22 Method of test: Air 24c.For Water kumply&Iniection Wells: In addition to sending the form to
the address(es) bove also submit one copy of this form within 30 days of
13b.Disinfection type: 70%HTH Amount:-12oz completion Of W111 Q 'qtruction'to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-D ivision'of Water Resources Revised 2-22-2016