GW1-2023-00717_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 DESCRII'TION
Well CuntracturName _ . +—'ram•
268 1"
3002-A 13.5 fc.
s, 330 1- 422 ft.
NC Well Contractor Certification Number pp 15 OUTF.RCASiNG(for timlti-cased-wells)OR T:iNF.R'(if'a
J livable)
Carolina Well Drilling AN 1 2023 FROM TO DL4METER THICKNESS MATERIAL
Company Name �:; pr •_?iU+:•':'fd 0 ft. 43 ff i"' SDR21 PVC
p y 22-422 ' '`'*""�t e; r 16:INNER CASING:OR TUBING( eothermal closed-loop).
2.Well Construction Permit#:
FROM TO DIAMETER In. THICKNESS MATERIAL
List all applicable well cunsnrtctian permits(i.e.UIC,County,State,Variance,etc.)
ft. ft.
3.Well Use(check well use): ft. ft. in.
17.,SCREEN
Water Supply Well: .
FROM TO DIAMETER SLOT SUP, THICKNESS MATERIAL
Agricultural QMunicipal/Public ft. ft. In.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. h.
Industrial/Cormnercial Residential Water Supply(shared) 18.GROUT
hTi ation FROM TO MATERIAL EMPLACEMENT METHOD tic AMOUNT
Non-Water Supply Well: 0 ft. 20+ n• Bentonite Pour(10)501b Bags
_Monitoring EIRecovery fL ft.
Injection Well: ft. ft.
Aquifer Recharge nGroundwater Remediation 19.SANDlGRAVF.T PACK(if applicable)
Aquifer Storage and Recovery []Salinity Barrier FROM TO MATPRLAL EMPI-,CEMENT METHOD
Aquifer Test []Stornwater•Drainage
ft. ft.
Experimental Technology 13Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DFSCRTPTiON(color,hardness soll/rock type.pratn site,etc)
Geothermal(Heating/Cooling Return) n Other(explain under#21 Remarks)
0 ft. 3 rt• Fill Clay
4.Date Wells Completed: Well ID# 3 ft' 20 ft.
() 11-23-22 P Brown Dirt
5a.Well Location: 20 ft. 600 ft• Blue Slate
Juan Arellano ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
2808 Snyder Store Rd.Monroe 28112 ft. ft.
Physical Address,City,and Zip
ft.
Union 04-009-005E 21.REN ARIrs
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degreeshninutes/seconds or decimal degrees:
(if well field,one latllong is sufficient) 22.Certification:
34.54.162 N 80.26.418 W ^- 1
1 Z-6-22
6-Is(are)the well(s)mPermanent or OTemporary giguature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an e)dsdng well: E]Yes or RNo with 15A NCAC 02C.0100 or)5A NCAC 02C.0200 Well Construction Standards and that a
if this is a repair,fill out blown well cnmaruction information and explain the nature of the copy of this record has heca provided in the well nnmer.
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 the back 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 INSTRUCTIONS
9.Total well depth below land surface: 600 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
Fm'multiple ivelis list all depths if dierent(example-3(a3200'and 2@100� construction to the following:
10.Static water level below top of casing: 35 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater 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,rotaryry,,cable,12.Well con method: construction to the following:
ble,,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276994636
13a.Yield(gpm) 1 Method of test: Air 24c.For Water Supply&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: 36oZ completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016