GW1-2023-02832_Well Construction - GW1_20230420

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver
Well Contractor Name FROM TO J DESCRUITIO I N
48 91
3002-A
174 198 1- 275,331,4157
KC Well Contractor Certification Number AS OUTERI:CASINg'(fite.inulti c a cased iv'ellsf OR TANRR,fif U bi V
a e)
Carolina Well Drilling FROM To DIAMETER.! THICKNESS P9 ILSIAITERik
Company Name 0 rt. 45 • 6 1/4 SDR21 PVC
INN,_16' .ER"CASING'OR TUBING J'6thirnaal d6sid-liati
2.Well Construction Permit 4t: 23-23 FROM TO -_ I DIAMETER I THICKNESS MATERIAL
List all applicable well consimcdon permits(i.e.UIC,Counky,State,Variance,etc.) ft. ft. I in. L
3.Well Use(check well use): ft. ft. in.
Water Supply Well:
FROM To DTAMVMR SLOT SIM THICKNESS MATFRTAL
:lAgricultural []Municipal/Public ft, ft. in.
:]Geothermal(Heating/Cooling Supply) nResidential Water Supply ft. ft. in,
DIndustrial/Commercial OResidential Water Supply(shared) _GROUT�,,�"`
zinigation FROM TO MATERIAL ENIPLACFAIENT METHOD&AMOUNT
Non-Water Supply Well: 0 20+ rt. Bentonite Pour(17)501b Bags
3Monitoring ORecovery
Injection Well:
t—&Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery rl Salinity Barrier FROM To I MATERIAL I FMPr-4,CEMENT METHOD
Aquifer Test OStormwater Drainage
Experimental Technology OSubsidence Control
Geothermal(Closed Loop) OTracer '-20.DRILLING,L0,G'Iittachadditioiialsheetsifndcessiryl)'>, .l"-�,.'-�.
Geothermal(Ileating/Coolirig Return) Other(explain under#21 Remarks) FROM TO DESCRTPTION(color,hardness,sollfrock type�gratti size,etc)
off13 Red Clay
4.Date Well(s)Completed: 3-2-23 Well ID# 13 34 Red Sandclay
Sa.Well Location: 34 ff 500 ft.
Granite
Circle S Ranch
Facility/Owner Name Facility ID#(if applicable) APR 2 0 2023
Austin Rd, 1,Well 1 Monroe 28112 ft ft.
Physical Address,City,and Zip ft. ft.
Union 04-189-005 ,`21-.`REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
34.49.143 N 80.32.737 W 3-8-23
6.1s(are)the well(s)faPermanent or OTemporary Signature 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 existing well: nyes or JoNo with ISANCAC 02C.0100 or 75A AICAC 02C.0200 Well Consimcdon Standards and that a
If this is a repair,fill out hiown well construction itifnrmalion and explain the nature of the copy nflhiv record has been provided in the well owner.
repair tinder#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 sarne 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: 500 24a. For All Wells: Submit this form within 30 days of completion of well
Foi-multiple wells list all depths if different(exximple-3@000'and 2@ 1 00r construction to the following:
10.Static water level below top of casing: 15 (ft.) Division of Water Resources,Information Processing Unit,
If water Wei 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
12.Well construction.method: Air Rotary above, also submit one copy of this,fo.rm within 30 days of completion of well
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 Ceker,Raleigh,NC 27699-1636
13a.Yield(gpm) 15 Method of test- Air 24c.For Water 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: 30oz completion of well construction to t I he county health department of the county
where constructed.
Form GW-I North Carolina Department of EnvironmentalQuality-Division of Water Resources Revised 2-22-2016