GW1--00946_Well Construction - GW1_20240208

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: '
1.Well Contractor Information:
I
Frankie L.Oliver „14:WATER ZONES ,'- ;` _.., '
FROM TO DESCRIPTION
Well Contractor Name 218 f6 343 R
3002-A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased'.,wells),OR LINER(inapplicable) '
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 48 ft- 6 1/4! in' S D R21 PVC
16.INNER CASING OR TUBING;"(geothermal closed-loop}
22-210
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,Slate,Variance,etc.) fL fL I, in.
3.Well Use(check well use): ft ft in.
717.SCREEN •Water Supply Well: FROM TO .Fm t.DIAMETER I SLOTSIM THICKNESS MATERIAL
Agricultural DMVIunicipallPublic ft. ft. In.'
Geothermal(Heating/Cooling Supply) )$iResidential Water Supply(single) IL ft. in,,
Industrial/Commercial DIResidential Water Supply(shared)
Is.GROUT , -_
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20+ ft. Bentonite Pour(19)50Ib Bags
Monitoring I (Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge ID Groundwater Remediation
19:SAND/GRAVEL PACK(if applicable) '-
Aquifer Storage and Recovery . OSalinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test (IStormwater Drainage ' ft. ft.
Experimental Technology IDSubsidence Control ft. ft. '
Geothermal(Closed Loop) Tracer 20.DRILLING,LOG{attach additional sheets if necessary)" r:
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,h ardness,soiUruck type,grain size,etc.)
0 ft' 35 ft. Brown Clay
4.Date Well(s)Completed: 11-29-23 Well ID# 35 ft. 500 ft. Blue Slate
5a.Well Location: ft ft
Paula Nguyen ft ft
Facility/Owner Name Facility ID#(if applicable) ft ft' t.L. d.A i "'
Wolf Pond Rd. Monroe 28112 ft ft
f[ f[ FED g 2024
Physical Address,City,and Zip
21 REMARKS a `
Union 04-174-013A frt er^ -n E1 i
County Parcel Identification No.(PIN) l fO oG
56.Latitude and longitude in degrees/inintites/seconds or decimal degrees: '
(if well field,one lat/long is sufficient) 22.Certification:
34.53.144 N 80.32.368 W
12-11-23
6.Is(are)the well(s)0Perinanent or OTeinporary ore of Certified well Contractor •
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: *Yes or ONo with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
lfthis is a repah;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#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 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 multiple wells list all depths if different(example-3 00'and 2@100') construction to the following: i
I
10.Static water level below top of casing: 22 (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 following: 1
(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) 3 Method of test: Air 24c.For Water Supply &injection Wells: in addition to sending the form to
the address(es) above, also submitione copy of this form within 30 days of
13b.Disinfection type: 70% HTH Amount: 30oZ completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016