GW1-2023-00714_Well Construction - GW1_20230113

WELL CONSTRUCTION-RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver 14.WATER ZONES
FROM TO DFSCRH'TION
Well Contractor Name -
73 ff 139 a.
3 -A 002FL _y(`[ Kry ,
r 4. v a e ft. ft.
q 324
NC Well Contractor Certification Number I j�} a� �(123 15.OUTER CASING(for mull-cased ivells)OR LiNER(if a licable)
Carolina Well Drilling JA ' 11�, FRONT TO DUNIETM THICKNUSS MATEALAL
Company Name y' yr�f
0 ff 45 ff 61/4 In, SDR21 PVC
22-249 et,� �vas, 16.INNER CASING OR TUBING.(geothermal closed-loop)
2.Well Construction Permit#:
� � FROM TO DIAMETER THICKNESS 11fATERLAL
List all applicable well consnucdon permits(i.e.UIC,Courtly,State,Variance,etc.) ft. ft, in.
3.Well Use(check well use): n. ft. in.
Water Supply Well: 17.SCREEN
PP ye FRONT TO DiAMF.TER SLUT SIZE THICKNFSS MATERIAL
Agricultural OMunicipal/Public n, tt, in.
Geothermal(Heating/Cooling Supply) JoResidential Water Supply(single) ft. rt. In.
Industrial/Cominercial [DResidential Water Supply(shared) 18.GROUT
I17lQatiUn FROM TO h1ATERIAY, E1nZACEI\IENTAIETHOD&ADIOUNT
Non-water Supply Well: 0 ft. 20+ ft- Bentonite Pour(15)501b Bags
Monitoring ®Recovery ft. ft.
injection Well:
rt. n.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVF.i.PACK(if applicable)
-
Aquifer Storage and Recovery DSalinity Barrier FROM TO 1%IRA LiL EMPLALIEA[ENT METHein
Aquifer Test E]Stonnwater•Drainage
ft. ft.
Experimental Technology ®Subsidence Control ft. ft.
Geothermal(Closed Loop) ®Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DFSCRH'TION(color,hardness soiltrock t ruln size etc.)
Geothermal(Herein /Coolie Return) Other(explain under#21 Remarks)
0 rc. 4 ft, Brown Clay
4.Date Well(s)Completed: 11-17-22 Well ID# 4 ft' 23 rt' Brown Dirt/Rock
5a.Well Location: 23 ft' 400 ft Granite
Butch &Lisa Ward ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1701 Tom Williams Rd.Monroe 28112 ft. ft.
Physical Address,City,and Zip ft. R.
Union 04-084-004C 21.RENI IRKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lar/long is sufficient) 22.Certification:
34.54.216 N 80.30.204 W `/'
12-6-22
6.Is(are)the well(s)oPermanent or OTemporary Signature of Certified W ontraccor Dace
Br signing this form.I hereby certify ihai the well(s)was(were)consinecled in accordance
7.Is this a repair to an existing well: ❑Yes or [RNo with 15A NC-AC 02C.0100 or 15.4 AICAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out bunri well construction itefomwtion and eaplai n the nant a of the copy of this record has been pmvided rn the well owner-
repair under#2I 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 well
construction,only I GW-1 is needed. Indicate TOTAL NUIViBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 400 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple welts list all depths if different(example-3@200'and 2(a3100� construction to the following:
10.Static water level below top of casing: 31 (it.) 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 Injection 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
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,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) 5 Method of test: Air 24c.For Water Supply&Iniection Wells: In addition to seeding the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type- 70%HTH amount: 24oz completion of well construction to the county health department of the county
where constructed.
Ftnm GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016