GW1--06788_Well Construction - GW1_20231024

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: '
1.Well Contractor Information: j
Frankie L.Oliver j ',14.WATESLZONESi 11._41 L, ,,s . -
. FROM TO DESCRIPTION i
Well Contractor Namei 165 ft. 411 ft. ,I '
3002-A f ft. ft.
I
NC Well Contractor Certification Number 1s.'ouTERICASING(foiabultiktiSed'lvells)OR LINER(if applicable) -
Carolina Well Drilling I FROM TO f DIAMETER THICKNESS ARTERIAL
Company Name 1 0 f 86 ft. 6 1/4 ' in. SDR21 PVC
23-1 81 ,16.INTIERCASING'OR TUBING'hieothermal cicaed lobe)
2.Well Construction Permit#: i FROM TO f DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. U/C,County,State,Variance,etc.) ft. ft. !i In. I
3.Well Use(check well use): ft. ct in
Water Supply Well: 1
I FROM TO . DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural O;Muuicipal/Public ft.. ft. 'iii.
Geothermal(Heating/Cooling Supply)I :Residential Water Supply(single) ft. It ;ti
Industrial/Commercial f DResidential Water Supply(shared) 1x;GROUT ay i
Irrigation • FROM - TO. MATERIAL. EMPLACE ENT METHOD&AMOUNT
Non-Water Supply Well: 1 0 ft- 86 ft. Beltonite Pump(15)501b Bags
Monitoring , f Recoveiy ft. ft. - I I
Injection Well:
ft. ft. ,
Aquifer Recharge 1 DGroundwatcrRemediation :19.SAND/GRAVEL'PACE(it applicable) -'.'1' ' -
'Aquifer Storage and Recovery 1 DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 1 DIStornnvater Drainage R. j ft. r i
Experimental Technology Subsidence Control ft. ft. ! i i
Geothermal(Closed Loop) Tracer '20.DRILLING.LOG(attach additional sheets:if necessary)4 .,. - _
Geothermal(Heatin•/Cooling,Retumj nOther(explain under#21Remarks)
FROM TO DESCkIPf10N(cotnr,ha>dnas5,sotUrucktypogreinsizeetcJ
0 ft 8 ft. Red Clay
4.Date Well(s)Completed: 9-11-23 Well ID# 8 n. 81 r4 Brown Clay .
5a.Well Location: 81 ft 500. ft Blue Slate
Clyde Heath rt. It I .t:I? '1;
� Y-
( '
rt. IL ..., '.
Facility/Owner Name Facility ID#(if applicable) OCTJ
Landsford Rd. Marshville 28103 ft. ft• I 2023
Physical Address,City,and Zip fa rt Ir!'�d,`;; i-'" ' •'- M':.,I rr.i•
Union 03-135-039 '21:REMARKS•> ,,, i 71..-1
County , Parcel Identification No.(PIN)
*Casing grouted full lengthlas required by permit
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -
(if well field,one lallong is sufficient) 22.Certification:
34.84.108 N 80.41.587 W
9-19-23
6.Is(are)the well(s)RiPermanent or Temporary Signature of Certified well ontractor Date
By signing this form.1 hereby certify that the well(s) was(were)constructed in accordance
7.Is this a repair to an existing well: jjYes or j!i No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill ant known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this fonn.
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: 500 - (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For nut/tiplc wells list all depths if different(example-3 00'and 2@100') construction to the following: i
10.Static water level below top of casing: 47 (ft.) Division of Water Resources,Information Processing Unit,
lf water level is above casing.use"+" • 1617 Mail Service Center,Raleigh,NC 27 699-1 61 7
11.Borehole diameter: 6 (in.) 24b.For Infection Wells:` In addition to sending the form to the address in 24a
Air Rotary • above, also submit one cop Within of this form 30 days of completion of well
12.Well construction method: construction to the following: { •
(1.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
i d
13a.Yield(gpm) -5 I 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: 30o2 completion of well construction ito the county health department of the county
I
where constructed. i
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Form GW-1 North Carolina Department of Environmental Quality-Division of Watcr,Resourets Revised 2-22-2016