GW1--02205_Well Construction - GW1_20240408

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: 1
Frankie L. Oliver :14.WATERZONE5 .r
WellContrec[orName FROM TO DESCRIPTION
3002-A 215 ft- 358 ft' 1
390 et. rt. I i
NC Well Contractor Certification Number iS.OUTER'CASING(tor'luultr i ased'lwells)OR LINER(if applicable)
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 48 ft* 61i;4,;'n• SDR21 PVC
Company Name '16.INNER CASING'OR TUBING(geotheru al closed-loop) .; '
2.Well Construction Permit#: 23-278 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): f4 ft. in
Water Supply Well ,.
Agricultural OMunicipal/Public j R ft ft. in
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) qy ft. ;n,
— Industrial/Commercial Residential Water Supply(shared) FROM TO DIAMETER : SLOT SIZE THICKNESS MATERIAL
IS:GROUT ,1.-,'`0i ." _ ,7,
Irrigation FROM TO . MATERIAL `• EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 20+ ft. Bent(inite Pour(10)501b Bags
Monitoring IIRecovety ft ft.
Injection Well: ft. ft.
Aquifer Recharge l Groundwater Rernediation •
yy SAND/GRAVEL PACK if applicable) .
( pp ,'
Aquifer Storage and Recovery �ISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ;riStorntwater Drainage ft. ft. ,
Experimental Technology DiSubsidence Control rt. ft.
Geothermal(Closed Loop) OTracer `20.'DRILLING LOG-(attach additional sheets if necessary`)(- . .t
J Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,suil/reck type,grain size etc.)
0 ft. 23 it Brown Clay
4.Date Well(s)Completed: 3-20-24 Well m# 23 rt. 400 ft. Blue'Slate
5a.Well Location: rt. ft.
Grace Croasmun rc It..
l:
Facility/Owner Name Facility ID#(if applicable)
7415 Olive Branch Rd. Marshville 28103 rt. ft. APR OF 20Z4
Physical Address,City,and Zi
ft. rt.
Ph
ys P 1,`--7. ..;, �; ,of-. !.,
Union 01-159-008B .21 REMARKS• :`„ 3°il: U"Jr =—l` _
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
•
35.06.639 N 80.38.015 W C,:�
3-28-24
6.Is(are)the well(s)EaPerrnanent or Temporary Signature of Certified well Contractor', Date
By signing this form, I hereby ce rf that the well(s)was(were)canstnected in accordance
7.Is this a repair to an existing well: jYes or 'MNo with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
copyofthis record has been provided this is a repair,fill out known well tonslruGiun it furmatioa and explain the nature of the p ovided fo the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well;detalls:
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: 400 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple welit list all depths if different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 19 (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 Service'Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 22 Method of test: Air 24c.For Water Supply&inie Ition 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: 24oz completion of well construction Ito l 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