GW1--06787_Well Construction - GW1_20231024

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: 1
Frankie L. Oliver 14.WATER ZONES -
Well Contractor Name FROM TO DESCRIPTION
3002-A 487 IL497 EL
ft. ft.
NC Well Contractor Certification Number • 15.OUTER CASING(for multi=cased wells)OR LINER(if applicable)Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 75 ft. 61/4 in. SDR21 PVC
Company Name '16.INNER CASING OR TUBING(geothermal closed-loop) '
2.Well Construction Permit#:
23-233 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction 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 DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 9Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) )yiResidential Water Supply(single) ft, ft. in.
Industrial/Commercial 9Residential Water Supply(shared) 111.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20+ ft. Bentonite Pour(23)50Ib Bags
Monitoring 9Recovery ft. ft.
Injection Well: It. ft.
Aquifer Recharge 0 Groundwater Remediation 19.SAND/GRAVEL PACK(it applicable)
Aquifer Storage and Recovery ['Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DIStomtwater Drainage ft. ft.
Experimental Technology ['Subsidence Control ft. ft.
Geothermal(Closed Loop) ['Tracer 20.DRILLING LOG(attach additional sheets if necessary) •
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) nOther(explain under#2I Remarks)
0 rt. 25 ft. Red Clay
4.Date Wells)Completed: 9-22-23 Well ID# 25 ft. 525 rt. Blue Slate
5a.Well Location: ft ft _ 7'", ,�
Kellen Lee rt. rt. ej .. :!,�:'
Facility/Owner Name Facility ID#(if applicable) ft' it. OCT 2 '• 2023
7408 Hwy.218 E Marshville 28103 ft. ft_
Physical Address,City,and Zip ft ft D:t y;i.7.-2.,•:"
Union 01-117-020B 21.REMARKS . .
County Parcel Identification No.(PIN)
5b.Latitude and longitude iu degrees/minutes/seconds or decimal degrees:
(if well field,one lat/loug is sufficient) 22.Certification:
35.12.183 N 80.35.371 W
Q ( 9-29-23
II Temporary Signature of Certified Well Contractor Date
6.Is(are)the well(s)OPermanent or
By signing this form, 1 hereby certify that the well(s)was(were)constncted in accordance
7.Is this a repair to an existing well: IJYes or j1 No with 15A NCAC 02C.0100 or 15A 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 the well owner.
repair under/121 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 attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 525 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For nudtiple wells list all depths.if different(example-3(d 00'and 2@100') construction to the following:
10.Static water level below top of casing: 41 (ft.) Division of Water Resources,Information Processing Unit,
if water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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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
(i.e.auger,rotary,cable,direct push,etc.) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) 2 Method of test: Air 24c.For Water Supply&Injection.Wells: In addition to sending the form to
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the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 70% HTH Amount: 34oz completion of well construction tol the county health department of the county
- where constructed. I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016