GW1--06786_Well Construction - GW1_20231024

}
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: I ,
Frankie L.Oliver .14.WATER ZONES _ ' 1
Well Contractor Name FROM TO DESCRIPTION
73 ft- 81 ft'
3002-A I .
155 ft. fL
NC Well Contractor Certification Number .15.OUTER CASING(for multi:cased wells)OR LINER(if applicable)
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 50 ft' 61/,4: in' SDR21 PVC
23-177 .16.INNER CASING'OR TUBING(geotherinaLclased-loop)':
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. 1 ' in-
3.Well Use(check well use): ft. ft. in
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipallPublic ft. it. in.
Geothermal(Heating/Cooling Supply) !ilResidential Water Supply(single) fL g, in.
Industrial/Commercial QResidential Water Supply(shared) -
18.GROUT .
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20+ ft* Bentonite Pour(17)50Ib Bags
Monitoring 0 Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge 0 Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable) _ <_." .' '
Aquifer Storage and Recovery 'DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD ,
Aquifer Test OStomiwater Drainage fL ft. .
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer .20.DRILLING LOG`(attach additional sheets if necessary) _ ' ^° -
Geothermal(Heating/Cooling Return) [Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
0 ft. 27 ft. Brown/Red Clay
4.Date Well(s)Completed: 9-27-23 Well ID# 27 fL 200 ft' Blue'Slate
5a.Well Location: ft. ft.
ft. r`,-
Jonathan Brewer ft. r .'.----0,.....,,L._` J.l a'`". >( )
""
Facility/Owner Name Facility ID#(if applicable) ft. FL
Hwy.205 Marshville 28103 ft- ft. I: O C T '' 2023
Physical Address,City,and Zip ft. tfi}:i t' `.^7�': -. i�:-.,
Union 01-111-006G 21.REMARKS . , 4 ' — ,.:a:
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degreeshninutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: •
35.90.725 N 80.21.200 W cc c - , 9-29-23
6.Is(are)the well(s)EaPennanent or D Temporary Signature of Certified Well Contractor Date
By signing this,form,I hereby certify that the well(s)was(were)constntcted in accordance
7.Is this a repair to an existing well: DYes or y!jtNo " with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to,ihe well owner.
repair under#21 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attachadditional pages if necessary.
drilled: , SUBMITTAL INSTRUCTIONS
depth below land surface: 200
9.Total well (ft)
24a. For All Wells: Submit this form within 30 days of completion of well
'For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following: I
f
10.Static water level below top of casing: 53 (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1 61 7
11.Borehole diameter: 6 (iu.) 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) 25 Method of test: Air 24c.For Water Supply &Injection Wells: Tn 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 the county health department of the county
where constructed. -
i
Form GW-1 North Carolina Department ot•Environmental Quality-Division of Water Resources Revised 2-22-2016