GW1-2022-09569_Well Construction - GW1_20221021

WELL CONSTRUCTION RECORD (GW-1) For Internal Us Only:
1.Well Contractor Information:
Frankle L.Oliver 4 4:2WATS R44 W O'S4 w-,�z,may J I
Well Contractor Na FROM TO _ DESCHUMON
58 82
3002-A
120 141,216,2 34
NC Well Contractor Certification Number 1j5.`jD1jTXRWA'SFN 14
Carolina Well Drilling FROM TO DIAMETER TFEECKNIESS MATERIAL
Company Num 0 ri- 46 ft. 6 114 In. PVC SDR21 i al ­�_�,-I "0-6 1"M&-wm"M va it Mrllu"
2.Well ConAructlon Permit 22-244 FROM TO DIAMETER TIUCKNESS MATERIAL
List all applicable well constriction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
_ _ORE N.1 -�W;&'M, j e�r
Water Supply Well: 41 FROM I TO DIAMFWR SLOTSIM THICKNESS I MATRRIAT.
Agricultural DMunicipalillublic ry 1L In.
Geothermal(Heating/Cooling Supply) ElResidential Water Supply in.
Industrial/Commercial ®Residential Water Supply(shared)
Irrigation FROM TO MATERIAL EAflqACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 Bentonlire Pour(16)501b Bags
3monitoring DRecovery
Injection Well:
3Aquifer Recharge 13Groundwater Remediation
01 9 WN 11/01k now,wgwm I rPA
lAquifer Storage and Recovery ®Salinity Barrier FROM, MATERIAL EMPLALIUWMNT MMOD
Aquifer Test [3Stnrtnwater Drainage ft.
Experimental Technology 13Subsidence Control ft.
Geothermal(Closed Loop) ®'racer 77777�,;W, � 4S
Geothermid(Heating/C oling Return) rIOther(explain under#21 Remarks lj FROM TO I T)TSCRTPTION(color�harditesit,wMrock bl;e,grain aht,etc.)
0 ft. I 1i f* Brown Clay
4.Date Well(s)Completed: 9-15-22 Well ID# i I 2� r. Brown Shale
Sa.Well Location: 2�5 r'. Blue�Jaje 'n,
ft. ft.
Andrew McCutcheon
— F
Facility/Owner Name Facility TD#(if applicable) ft.
2314 Fletcher Broome Rd.Monroe 28112 ft. ft.
Physical Address,City,and Zip ft. ft.
­21" 777 7,
Union 09-357-039A 7VT-7.7=77*7777777,
County PkuM Identification No.(PIN)
5b.Latitude and longitude In degrecsWnutes/seconA6 or decimal degrees:
(if well field,one IdYiong is sufficient) 22,Certification
34.56.422 N 80.35.349 W 9-26-22
__ —
6.Is(are)the well(s)OPerrminent or 13Temporary Sign FVF of Catifi Well Contractor Date
BY signing lhisjb4n.7,hereby cerfify that the well(s)was(were)comirucled in accordance
7.Is this a repair to an eidsOng well: ®Yes or Jallo with 15ANCAC 02C.0100 or ISA NICAC 02C.0200 Well Cowtruction Standards and that a
If this is a repair,fill out bimm well commulinn ittformatinn and explain the nature of the copy of ties remrAtu been jornvidedin the well owner.
repair tinder#21 remarks section or on the back of iris form.
23.Site diagrattqq or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use th back of this page to provide additional well site details or well
constsuctionde#s. You may also attach additional pages if necessary.
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells
drilled: TVDftA!1f`1r-rAT INSTRUCTIONS
9.Toud well depth below land surface: 275 (ft-) 24a. Subtinit this form within 30 days of completion of well
Fnr muldpleweliv lict all depths((different(e.unnple-3@200'and 2@100� eonstlUetiOn t0 a following:
10.Static water level below top of casing: 25 (ft.) Division of Water Resources,Information Processing Unit,
If"ter level is above casing,tire I i 1 17 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Intec on Wells: In addition to sending the form to the address in 24a
Air Rotary above, also sub nit one copy of this form within 30 days of completion of well
12.Well construction method: construction to I 2e following:
(i.e.auger,rutury,cubic,direct push,etc.)
Division of Vater Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1 36 Mail Service Center,Raleigh,NC 27699-1636
j
13a.Yield(gpm) 20 Method of test- Air 24c.For Wate-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: 18oz completion of ell construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resourc.0 Revised 2-22-2n 16