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HomeMy WebLinkAboutGW1--02205_Well Construction - GW1_20240408 i 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