GW1-2023-02838_Well Construction - GW1_20230420

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information:
Frankie L.Oliver .14..WATER ZONES.
Well.Contractor Name FROM TO DESCRU'TION
3002-A
70 rf 119 et.
287 rf 315 et.
NC Well Contractor Certification Number i5.OCITRR CASiNG.(for multi-cased ivells)UR i.iNF.R(ifa licable)
Carolina Well Drilling FROM TO DIAMETER THICKNESS � MATERIAL
Company Name
0 ft' 44 rt, 61/4 1 SDR21 I PVC
23-04 16..INNER CASING OR TUBING'(eothertnal closed-lao )''.,
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well consnticdon permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. In.
Water Supply Well: 17,.SCREEN
FROM TO DTAMF.TF.R ST.OT SUP TMCKNRSS MATF.RrAT.
Agricultural nMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) QResidential Water Supply(single) ft. ft.
Industrial/Commercial OResidential Water Supply(shared)
lR.GROUT -
IrIi ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20+ ft- Bentonite Pour(13)501b Bags
Monitoring EiRecovery
Injection Well:
Aquifer Recharge E]Groundwater Remediation 19.SANDLGRAVF.i,PACK fit applicable)
Aquifer Storage and Recovery nSaliniry Barrier FROM TO MATERIAL E6iPLACFAIFNT MEMOD
Aquifer Test []Stonnwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additioual sheets if necessary):
FROM TO DFSCRTPTTON(color,hardness selltrock rein size etc
'Geothermal(Hearin /Conlin Return) � Other(explain under#21 Remarks)
0 ft. 21 ft, Brown/Red Clay
4.Date Well(s)Completed: 3-3-23 Well ID# 21 ft' 400 rt' Granite
ft. ft. --
5a.Well Location: f "
177
Camp Sutton Nursery
Facility/Owner Name Facility ID#(if applicable) ft. it. APR
l r1 -2 ® 2023
1801 E.Roosevelt Blvd.Monroe 28112 et. ft. f i�
Physical Address,City, ft.
,and Zip if17G+ri!sr,l'.,
Union 09-155-001 B 21.REMARKS "
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:
34.58.356 N 80.30.234 W
3-6-23
6.Is(are)the well(s)mPermanent 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: [3Yes or [allo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well,Construction Standards and that a
Ifihis is a repair,fill out kunim well construction irr(orntation and explain the nature of the copy of this record has been provided to the well numer.
repair under#2I 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: 400 (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple welk list all depths ifdif(erent(exeimple-3L200'an d 2@100� construction to the following:
10.Static water level below top of casing: 47 (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 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) 15 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. 24oZ 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, i Revised 2-22-2016