GW1--05821_Well Construction - GW1_20230901

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: I
1.Well Contractor information: i
i
Frankie L.Oliver :14.WATER,ZONES..: . <. .. '.k''t `
FROM TO DESCRIPTION
Well Contractor Name
114 ft. 118 ft.
3002-A 156 ft' 169 ft' 172,174•
NC Well ContractorCectification Number 15.;OUTER.CASING(for.multicased Wells)OR'i.INF.R(If aplicable) :
Carolina Well Drilling FROM TO DIAMETER I THICKNESS MATERIAL
0 ft' 92 ft' 6 1/4 I'in' SDR21 PVC
Company Name
16.INNER`CASING'OR TUBING,(geothermal closed-loop);.
2.Well Construction Permit# 23-69 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well constriction permits(i.e.UIC,Cousin,State,Variance,etc.) fL It. hi.
3.Well Use(check well use): ft. ft.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL,
0Agricultural •Municipal/Public ft. it. in.
QGeothermal(Heating/Cooling Supply) EaResidential Water Supply(single) ft. g• in. '
DIudustrial/Comrnernial DResidential Water Supply(shared) '
'IiIigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20+ ft' Bentonite Pour(22)501b Bags
1:3Monitoring ORecovery ft. ft.
injection Well:
ft. ft.
Eli Aquifer Recharge D Groundwater Remediation
19:'SAND/GRAVEi.PACK(if applicable) :.'. - . -
0Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL• EMPLACEMENT METHOD
JAquifer Test 0Stormwater Drainage It. It.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop)B Tracer 20.DRILLING LOG(attach additional,sheets if necessary) -'.-` .. 2 ?
Geothermal(Heating/Cooling Return) Other(explain under 4121 Remarks) FROM TO DFSCRTPTiON(color,hardness,sell/rock type grain s1ze,etc.)
0 ft. 28 it. Brown Clay
4.Date Well(s)Completed: 8-8-23 Well ID# 28 ft' 56 ft' Red Clay
5a.Well Location: 56 ft. 60 re. Brown Sandclay
Southern Interior Design 60 ft. 83 ft. Soft Blue Slate .—r•-•" ,. r1-�r
Facility/Owner Name Facility ID#(if applicable) 83 it 200 ft. Blue lateS Fs a L, a " L.is....
Creek Township Farms Lot#1 Marshville 28103 ft. ft. i 1 Z
Physical Address,City,and Zip
ft. ft. SEP 4 _ 242v
Union 03-114-002A 21.REMARKS' •1ni—r -other r r.:7:A :* U11.:
10VjaiSO
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:
34.49.502 N 80.23.544 �, j'
i' 8-15-23
6.Is(are)the well(s)MPermanent or OTemporary Signature of Certified Well Contractori 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: El Yes or 151No with 15A NCAC 02C.0100 or 75A 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 1121 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 pager 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: 200 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3L200'and 2@100') construction to the following: I
I,
10.Static water level below top of casing: 24 (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 followine:
(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
1
13a.Yield(gpm) 20 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: 12oz completion of well construction to thel 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