GW1--05816_Well Construction - GW1_20230901

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
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1.Well Contractor information:
Frankie L.Oliver I4.WATER'ZONES
Well Contractor Name FROM TO DESCRIPTION
236 it' 251 ft' f
3002-A -
280 ft. 287 ft. 295,3211,345,366,372,389
NC Well Contractor Certification Number
15.OUTER'CASiNG(for multi-cased:wells)ORidNF.R(if'ap livable)' ,
Carolina Well Drilling FROM TO DIAMETER I THICKNESS MATERIAL
0 ft' 44 ft' 61/41 in. SDR21 PVC
Company Name '16.-INNER CASINC.OR TUBING;(geothermal closed-loo -`'
22-236 THICKNESS
2.Well Construction Permit#: FROM TO DIAMETER I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. 1 in.
3.Well Use(check well use): it• it. i in.
17:SCREEN.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public fL ft, in.i
Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) it, i4 in,,
Industrial/Commercial *Residential Water Supply(shared) is GROUT a ' -`-
Inigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20+ ft- Bentonite Pour(12)50Ib Bags
Monitoring DRecovery ft. ft.
I.
injection Well: ft. ft.
Aquifer Recharge 0Groundwater Remediation 19.SAND/GRAVF.T PACK(if applicable)
Aquifer Storage and Recovery 0Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test ED Stormwater Drainage
ft. ft.
Experimental Technology OSubsidence Control ft. ft.
1.
Geothermal(Closed Loop) EjTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,son/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) nOther(explain under 4/21 Remarks)
0 ft. 13 ft' Brown1Clay
4.Date Well(s)Completed: 6-13-23 Well ID# 13 ft' 425 ft' Blue Slate
5a.Well Location: ft. ft.
Brian&Jade Seeley ft. ft, R z -',i J a:.: -'I
ft. ft. i t %1—
s lr Y �_�
Facility/Owner Name Facility ID#(if applicable)
1104 Diana Lee Ln. Monroe 28112 ft. ft. SEP J 1 .ZQZ3
Physical Address,City,and Zip ft. ft. .
21.-REMr1RKS'' ' int0inr":���' .rc�:ti t;t'
Union 04-195-012F LA%(..5's`,. ..
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degreeshninutes/seconds or decimal degrees:
(if well field,one lat/lon is sufficient)B 22,Certification:
34.92.179 N 80.56.809 W i 7-6-23
6.Is(are)the well(s) Permanent or fTemporary atnre of Certified Well Contractor f Date
6,
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: ill Yes or igNo with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill our known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#l21 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 1.
9.Total well depth below land surface: 425 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-36.2)200'and 2(1100') construction to the following:
10.Static water level below top of casing: 27 (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: 1 '
(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&Injection':Wells: In addition to sending the form to
the addresses) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 70%HTH Amount: 260Z completion of well construction to the!county health department of the county
where constructed.
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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