GW1--06793_Well Construction - GW1_20231024

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information:
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Frankie L.Oliver .14:,WATER ZONES'.. :'z ,''. .r•-. ''
WellContrw[orNaine FROM TO DESCRIPTION
105 ft• 264 ft'
3002-A 455 ft' 646 ft' I
NC Well Contractor Certification Number
15.OUTER CASING(for multi-casedwells)_OR LINER(Map livable)
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
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0 ff 43 ft' 61/4 in' SDR21 PVC
Company Name
23-223 ,16.INNER CASING'OR TUBING:(geotherinal closed-loop)'; -
2.Well Construction Permit II: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: I7.SCREEN , . ; :' 't., - , '- , , .
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural $Municipal/Public ft. ft. in:
ir Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) h • ft. in:
IndustrialiConunercial OResidential Water Supply(shared)
181 GROUT ' :- -
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20+ ft. Bentonite Pour(17)501b Bags
Monitoring ORecovery ft. ft.
injection Well: •
ft. ft.
OAquifer Recharge OGroundwater Remediation
l9.SAND/GRA VF.I;PACK(if applicable)' `
Aquifer Storage and Recovery D Salinity Barrier FROM TO MATERIAL EMPLACEMENT_PLACEM__ MET_HOD_•
Aquifer Test OStarmwater Drainage
ft. ft.
OExperimental Technology OSubsidence Control ft. ft.
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Geothermal(Closed Loop) O.I Tracer 20.DRILLING'LOG(attach additional sheets if necessary), '_
Geothermal(Heating/Cooling Return) l Other(explain under#421 Remarks) FROM TO DESCRIPTION(color,hardness,solUrock type,grain size,etc.)
0 ft• 6 ft' Red Clay
4.Date Well(s)Completed: 8•4-23 Well ID# 6 ft' 17 it' Brown Clay
5a.Well Location: 17 ft' 726 ft' Blue'Slate .
Alexander Chepurnoy ft. ft. .''' :r� , ',/ ,L7 7�i
: n"� ,
"' -'•r
Facility/Owner Name Facility RN(if applicable) ft. ft. 7
4706 Old Pageland-Marshville Rd.Monroe 28112 ft. ft. ls,`� 1 f Z�Z3
Physical Address,City,and Zip ft ft, r n r f
Union 03-129-003B 21:,REM4RKR."': m : , _ ..
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: --
(if well field,one let/long is sufficient) 22.Certification: •
34.87.412 N 80.40.812 W •
_ if! , 8-25-23
6.Is(are)the well(s)MPeranent or OTemporary �ignamre of Certified Well Contractor Date
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By signing this farm,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or RiNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill nut brown well construction information awl 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 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 l 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: 725 (it.) 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@1O0') construction to the following:
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111.Static water level below top of casing: 25 (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 dills:formwithin 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
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13a.Yield(gpm) 1 Method of test: Air 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also subniit one copy of this form within 30 days of
13b.Disinfection type:-70%HTH Amount: 42oz completion of well construction ti the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016