GW1--04451_Well Construction - GW1_20230710

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: :
1.Well Contractor information: , ,
Frankie L.Oliver 44i1VATEwzoNEs .. .. wl, l. . .,: t .i
Well Contractor Maine FROM TO'I `DESCRIPTION
3002-A 59,62 ft• 15$ fe•
181 ft' 1m6 H• 298,331,393,406
NC Well Contractor Certification Number 13I'OUTFR2CASiNG'Yfor.r ulti t.eeed>wells)OR;iLiNFIR(illdp Ilcahle): -..
Carolina Well Drilling FROM ' TO'i 4 'DIAMETER THICKNESS ' ` MATERIAL
Company Name 0 ft' 44, I .6 I1/4 in' SE1R21 PVC
23-79A 16.INNER CASi11i.G nR TUIIINeti°(geathertitatelosed loop)a% apt_:.
2.Well Construction Permit 41: • FROM • TO I ii • .DIAMETER THICKNESS MATERIAL
List all applicable well construction pennits(i.e.UiC,County,State,Variance,etc.) ft. , ! ft. • iu.
1
3.Well Use(check well use): ft. ft. hi.
-17,SCREEN ;4, 0 s .;7 ;". :
Water Supply Well: FROM TO i DIAMETER x'Sl.OTSIZE THICKNESS MATP.RiAl,
Agricultural DMunicipal/public it. ;a. iu
Geothermal(Heating/Cooling Supply) QResidential Water Supply(single)
i
1 �, to
1$:GROUT..
Industrial/Cotmnercial ORecidential Water Supply(shared) , ,y ,.
, .
IIrrigation :
FROM TO 1 I `MATERIAL EI:PL ACE?,ENr METHOD&AMOUNT
Non-Water Supply Well: 0 ft, 20+ ft. 6entonite Poiir(15)501b Bags
Monitoring •DRecovery ft. ' I • ft. '
injection Well: It. 1 L. ft.
Aquifer Recharge ®GroundwaterRemediation • P19 SAND/GRAVEMPACK:(ifnp)lteehie) r t " 4.4; ir.
Aquifer Storage and Recovery 'Salinity Barter. FROM TO i' ' MATERIAL • EMPLACEMENT METHOD
Aquifer Test9
OStormwater Drainage ft. Ct.
Experimental Technology Subsidence Control ft. I ft.
OGeothennal(Closed Loop) Tracer <20ilDRII:LINaLOG(attach additiet al'aheetatfaecet,.tatyi ;, t,` ,. ^m;,. t';,?'
Geothermal(Heating/Cooling Return) Other(explain under 4121 Remarks) EROM TO 1 f, DESCRIPTION RiPT1o• (color,hardness,eaO/roek type,grain sire,etc)
. 0 et. 6 H Red Clay � .
4.Date Well(s)Completed: 5-8-23 Well ID#I 6 ft. 19 ft' Brown Clay/Rock
53.Well Location: 19 ft' 500 n. Granite
David Hyatt ft. rt. _ f z +
Facility/Owner Name :Facility II)11(if applicable) •ft. fl. y tit,... ...f'�.,d 1,. v - .
;3110 Tarlton Mill Rd.Marshville 28103 It. et.
Physical Address,City, Zipft. ft. i 61 1 0 2023
Ph
Y Y
Union 01-183-004 21 REMi.ARES >¢, „4;,..;' „�r,fy. ( + �.' _...7` .. „s :2n.n.-
ins ,,t 4„ ' -J t •
County Parcel Identification Nu.(PIN) I hn' `'s
5b.Latitude and longitude In degreeshiilnutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification; .
35.40.602 N 80.23.514 W 1
-�-� 6-5-23
6.Is(are)the wells) Permanent or Temporary Signature of Certified Well Contractor Date
.By signing this farm,I hereby serf y that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: al Yes or ONo with 1SA NCAC;02C.0100 or/SA IVCAC 02C.0200 Well Cornmtclion Standards and that a
If this is a repair,fill nut lawien m well constctiein information and explain the nature of the copy njlhrs record has beenpmvrd d to the well owner.
repair render i121 remarks section or on the back of this form.
23.Site diagram or addition well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same 'You may use the back of this age to provide a ditional well site details or well
construction,only i GW-i is needed. Indicate TOTAL NUMBER of wells construction details. You may Iso attach additi al pages if necessary.
drilled; SUBMITTAL INSTRUCTIO S
9.Total well depth below land surface: 500 (ft.) 24a. For MI Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3011200'and 2(0100) construction t0 die following:
10.Static water level below top Of casing: 42 (ft.) Division of Water esources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Servi a Center,Raleigh,NC 27699-1617
11,Borehole diameter: 6 (inn) 24b.For Needn't Wells: In addition to sendu g the form to the address in 24a
Air Rotary above, also st+binit one copy f this form withi 30 days of completion of well
12.Well construction method: construction to the following:
(Le.auger,runny,cable,direct push,etc.) , i
Division of Water Resoµr ,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: i1 t%36 Mail Servi��ce Center,Raleig ,NC 27699-1636
13a.Yield(gpm) 32 Method of test: 'Air 24c.For Water;Supply&•In'jection Wells: addition to sending the form to
the address(0) above, also s bmitl one copy f this form within 30 days of
13b.Disinfection type: 70%HTH Amount: 300Z completion of Well construcuon to the county ealth department of the county
where constructer.
1 ,
Fours OW-I North Carolina'Departmeht of Environmental Quality-Division of Water Rego trees ! . Revised 2-22-2d16
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