GW1--02196_Well Construction - GW1_20240408

WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only: !
1.Well Contractor Information:
Frankie L.Oliver ?.14.WATRICZONES 1,f„ .
Well Contractor Name FROM TO DESCRIPTION
3002-A 162 f` ft'170 f
242 ft' rt.
NC Well Conauctar Certification Number 1.:41S:OUTER:CASING;(foriuuld4ased,WellssOR'LINER!(if:iip'licablo) ,.,s M ,'-,':?.
Carolina Well Drilling FROM TO DIAMETER 1 THICKNESS ALa1TERiAL
Company Name 0 f` 150 ft' 6l/4� in SDR21 PVC
395249 w 16.INNER'.CASINGOR TUBING:(aeotherniii cloied-loop)'.n, ,.`' _,,• r .
2.Well Construction Permit#: FROM TO DIAMETER 1 THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. IL 'j In.
3.Well Use(check well use): ft. ea ; in
Water Supply Well: .,711 SCREENV, A in ^' w q t i ;kl v,,'6 .;,:, r y, , W"i",,a ,:.-4r
FROM TO DIAMETER 1 SLOT SIZE THICKNESS MATERIAL
1 Agricultural OMunicipal/Public ft. ft. in., •
ig Geothermal(Heating/Cooling Supply) ,MRe.eidential Water Supply(single) ft. R, in.;
Industrial/Commercial EDResidential Water Supply(shared) vIKGROUT`y :,g,; ,,,; ti .c.. (1 _,, N,. , 4'e l<:i
II Irri•ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 f 20+ f` Bentonite Pour(43)50Ib Bags
R Monitoring Recovery ft. ft. '
Injection Well: ft. It.
111 Aquifer Recharge , DGroundwater Remediation
t19f'SAND/GRAVEL PACK:(itappBcablel a.4, '1' ._-:., ."--..:',• ,.r':
$'Aquifer Storage and Recovery Cjisalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
*Aquifer Test oStormwater Drainagert. ft. '
,1 Experimental Technology QSubsidence Control ft. ft. i
Geothermal(Closed Loop) OTracer 2041IULLIN(f OG(intach udditionalshieets'if,neeeisar'y)'fi r ,:h, :;.:r `.,. tee;.-> ,,
FROM TO . DESCRIPTION(color,hardness,solrock type,grain size,etc.)
iii Geothermal(Heating/Cooling Return) nOther(explain under#2l Remarks) 0 f` 27 f` Red Clay
4.Date Well(s)Completed: 2-28-24 Well ID# . 27 f` 140 f` Brown Clay/Rock
5a.Well Location: 140 ft- 300 f` Granite T_,
Seth Lambert ft. rt. 1 .:'.k. E+..,n ii ' 'I 1
Facility/Owner Name Facility ID#(if applicable) ft. rt. I
20692 Running Creek Church Rd. Locustft. ft. APR 0 e 2024 28097 ,
Physical Address,City,and Zip It. ft. j Inf�:;r":.,.;1?r7a^:�,,;nn Lr 16
Stanly 20987 "-21 :REMAttfts ii.. i a ° tt;?..-:,';+ ; .': y p z. >i; t,M-s .,
.d.Etr1:l,L')��,. Y .Y,Y.4...E, t� �
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/ininutes/seconds or decimal degrees: '
(if well field,one lat/long is sufficient) 22.Certification:
35.30.173 N 80.37.310 W 4 '''' ic ,a : 3-15-24
6.Is(are)the well(s).i Permanent or .Temporary Signature of Certified Well Contractor Date
By signing this,fan,,.1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or No with ISA 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 at 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 constructionalso attach additional pages if necessary.
details. You may
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 300 (ft-) 24a. For All Wells: Submit his form within 30 days of completion of well
For multiple wells list all depths if different(example-3(a 200'and 2@100') construction to the following:
10.Static water level below top of casing: 35 (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:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Servii,Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 3 Method of test: Air 24c.For Water Supply &intection Wells: in addition to sending the form to
the address(es) above, also s(lbtnit one copy of this form within 30 days of
13b.Disinfection type: 70% HTH Amount: 18oz completion of well construction,to the county health department of the county
where constructed.
Form GW-1 North Carolina Department or Environmental Quality-Division of Water Resources Revised 2-22-2016