GW1--02206_Well Construction - GW1_20240408

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
t
Frankie L.Oliver 14.WATER ZONES'. ,A.-'( -
Well Contractor Name FROM TO DESCRIPTION
3002-A 160 ft. 240 ft. 1
ft ft.
NC Well Contractor Certification Number 15:OUTER';C'ASING(forniultr eased wells)OR'LINER(if applicable)
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 116 ft' 61)4, in. SDR21 PVC
16.1NNER.CASINGOR TUBING'(geothermal.closed-loop) '. -- •
24-82
MATERIAL2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) ft. ft. I' in.
3.Well Use(check well use): ft ft I. in
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. In.
Geothermal(Heating/Cooling Supply) .y'Residential Water Supply(single) fh ft in. •--
Industrial/Commercial OResidential Water Supply(shared) •'-
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20+ ft' Bentonite Pour(12)50Ib Bags
Monitoring ORecovery ft. ft. .
Injection Well: ft. rt.
Aquifer Recharge I©IGroundwater Remediation 19.SAND/GRAVEL°PACK(if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test DIStormwater Drainage ft. ft. I.
Experimental Technology 0Subsidence Control ft. ft
Geothermal(Closed Loop) Tracer ,...20.-DRILLING LOG{attach(additional sheets if necessary)-',' ` "' -"
Geothermal(Heating/Cooling Return) �....IlOther(explain under#2i Remarks) FROM TO DESCRIPTION(color,hardness,soil/ruck type,grain size,etc.)
0 ft 2 ft- Red;Clay
4.Date Well(s)Completed: 3-26-24 WellID# _ 2 ft- 28 ft' Brown Clay
5a.Well Location: 28 ft. 500 ft Blue Slate
Mary Carter ft. ft.
Facility/Owner Name Facility ID#(if applicable)
ft. it. .r w..�i; ;.1" �7.:. ;'
1012 E. Sandy Ridge Rd. Monroe 28112 ft. f. '. APR OS 20Z4
Physical Address,City,and Zip ft rt. in{-;y:^r:^:l ?''--.x^•¢:__^(1.
Union 04-120-002B '-21.REMARKs.,,, ,;,,1: 1,.:•4 m, r-.: -
County Parcel Identification No.(PIN)
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
34.89.393 N 80.52.121 W j
— .42.z , 4-3-24
D(Telnporary Signature of Certified Well Contractori. Date
6.Is(are)the well(s)MPerinanent or
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: DYes or RiNo with 15A 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 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 INSTRUCTION S
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@200'and 2Q100') construction to the following:
10.Static water level below top of casing: 50 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Servicet 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) 1 Method of test: Air 24c.For Water Supply&Tniec,tio,n Wells: To 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: 30oz completion of well construction to the county health department of the county
where constructed. 1
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources; Revised 2-22-2016