GW1-2022-09209_Well Construction - GW1_20220930

WELL CONSTRUCTION RECORD (GW-1), For Internal Ufie Only:
1.Well Contractor information:
Frankie L.Oliver J*WA'1Z Z0
FROM TO UESCRD'TION
Well Cuntrat:tur Name f
97
3002-A
rt. ft.
NC Well Contractor Certification Number f5:yd 17+R+(§t151N6(r8ir uNlrCaiFiB yellsIt1<1NR1t_ifra
Carolina Well Drilling FROM To I DIAMETER TH OOLIS MATERIAL
Company Name 0 rt. 43 n' 6 1/4;i" SDR21 PVC
21-427 ic�tNNIt.R- .Crtl ' ]a!tc a1 Flusea46 i` 14li 1 .. .�
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATFAIAL
List all applicable teen cuturniction peimiis(i.e.UIC,County,State,Variance,etc.) [t. ft. In.
3.Well Use(check well use): n. ft. In.
Water Supply Well: "t7Sf3iftilil+l(.. ':1� x� +�.. F' 7.)
pp y FROM TO I niAMF:TFJt I SLOT WE TRICKNFSS I MATF.RTAi
Agricultural ®Municipal/Public tt: n. is
Geothermal(Heating/Cooling Supply) ® ft. n•Residential Water Supply(single) f in.
Indusuial/Commercial 13Residential Water Supply(shared)Irrigation
Geothermal
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 n• 2 + n' Bentonite Pour 13 501b Bags
Monitoring Recovery rL n.
Injection Well:
ft ft.
Aquifer Recharge ®Groundwater Remediation Wit
Aquifer
Aquifer Storage and Recovery ®Salinity Barrier FROM TO MATERIAL E.MM.ALMENT METHOD
Aquifer Test ®StormwaterDrainage ft. n.
Experimental Technology ®Subsidence Control n. I n.
Geothermal(Closed Loop) ®Tracer ="2t1 bttil.[i1NG j 1; ittach ddifl811"teei�a+rffiece`ksa" .�t... _ i. w t.;:'';;
Geothermal eado /Conlin Return) Other(explain under#21 Remarks FROM I TO J nFSCRTPTTON color,hardness soNrock tyM grain sou etc
0 fL 21 ft' Brown Clay/Shale
4.Date Well(s)Completed: 8-29-22 Well ID# 21 tf 200 n' Blue Slate
ft. n.
So.Well Location:
n.
Victor Belii n.
Facility/Owner Name Facility M#(if applicable) n:
Hemby Woods Lot#20 Moser Circle Indian Trail 28079SEP
Physical Address,City,and tip ft. ft. t
Union 07-042-018 z t'�1IViAitEfi", v a,one.. - r 'r
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degreeshninutes/seconds or decimal degrees:
(if well field,one[at/long is sufficient) 22.Certification.
35.40.132 N 80.36.554 W
G�'o7� 9-19-22
Signature of Cenificid Well Contractor Date
6.Is(are)the wells)faPermanent or Temporary I
By signing/his forum.1 hereby cenift them the well(s)war(were)conslracled in accordance
7.Is this a repair to an existing well: ®Yes or Jallo with 15A NCAC 02t.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Uthis is a repair,fill was bvnsn well constructinu ittfarnwtinn atul explain the nature of the copy of this record has keen pmvided in the well owner.
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 thelback of this page to provide additional well site details or well
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL&MUCTIONS
9.Total well depth below land surface: 200 i
(ft-) 24a. For All Wells: Submit this form within 30 days of completion of wel I
For multiple wells list all depikv jf d(fferent(example-3(a3200'and 2@100) construction to the following:
10.Static water level below top of casing: 24 (ft.) Divisio' of Water Resources,Infornwtion Processing Unit,
If ivoler kvcl is above casing,use"+" 16 7 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (fn.) 24b. or ec n Wells: In addition to sending the forty 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 th�following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of 4ter Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 163,6 Mail Service Center,Raleigh,NC 27699-1636
13s.Yield(gpm) 14 Method of test: Air 24c.For Water SuDDiv&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: 12o2 completion of w4ll construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division�of Water Resources Revised 2-22-2016
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