GW1-2022-10593_Well Construction - GW1_20221122

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information:
Y
Frankie L.Oliver ,14.;WATER ZONES.
Well Contractor Name FROM TO DESCRIPTION
48 e. 137 ft.
3002-A
212 ft. 2 ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased,wells)OR LINER(I ap livable)
Carolina Well Drilling FROM TO DLAMETER THICKNESS MT9 E) L
CompanyNatne 0 ft. 45 It' 611A in. SDR21 PVC
16.INNER CASING OR TUBING(geothermal closed-loop), "
2.Well Construction Permit#- 22-252 EI
TO DIAMETER THICKNESS MATERIAL.
List all applicable well constntction permits(i.e.UIC,County,State,Variance,etc.) ft. in.
3.Well Use(check well use): ft. m.
Water Supply Well: N
TO DIAMETER Si.OT SIZE THICKNESS MATFRTAAgricultural ®Municipal/Public IL in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fL In.
Industria1/Commercial Residential Water Supply(shared) T
�j ation TO MATF.RUL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. 20+ ft. Bentonite Pour(9)501b Bags
Monitoring Recovery
injection Well:
Aquifer Recharge ®Groundwater Remediation 19.SAND/GRAVE .PACK(if a livable)'-
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERL4.L Elttt4 ACEMENT METHI ID
Aquifer Test [)Stonnwater ft. ft.Drainage '
_ Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) ®Tracer 20:DRILLING LOG(attach additionai sheets if necessa ),; -
FROM TO DFSCRTPTION(color,hardness soiltrock rain size etc)
_Geothermal(Hearin /Conlin Return) _ Other(explain under 421 Remarks) FROM
It• 23 it- Brown Clay/Shale
4.Date Well(s)Completed: 11-14-22 Well ID# 23 Il. 300 ft' Blue Slate
Sa.Well Location:
ft. ft.
Daniel&Laura Wilson
ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. fl. �� L V 4::.l
Joe Griffin Rd. Monroe 28112 ft. ft.
Physical Address,City,and Zip
ft. ft.
Union 04-036-025C zl:REntARKs =^ � M. T.9 U nR
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degreeshninutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) 22.Certification:
34.54.131 N 80.127.387 W
11-15-22
6.Is(are)the well(s)faPermanent or 13Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify Am the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 13Yes or MNo with 1SA NCAC 02C.0100 or 75A NCAC 02C.0200 Well Construction Standards and that a
If this&a repair,fill out known well conetruclion informatinn and explain the nature of the copy of this record hoe been provided to the well owner.
repair under#21 remarks section or on the back of this farm.
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 I
construction,only I GW-1 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: 300 (ft.) 24a. For All Wells: Submit this form vvithin 30 days of completion of well
For multiple wells lift all depths if different(example-3(a)200'and 2L700� construction to the following:
10.Static water level below top of casing: 26 (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
(i.e.auger,rotary,cable,direct push,ut 12.Well construction m construction to the following:
ushh,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&Infection 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 well construction to!the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division ofWatcr Resources j Revised 2-22-2016