GW1--05107_Well Construction - GW1_20240827

WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Well Contractor Information:
Frankie L. Oliver 14.WATER ZONES
FROM TO DESCRIPTION — I
Well Contractor Name
100 ft. 225 ft*
3002-A rt
383 . ft.
NC Well Contractor Ceniftcatinn Number 15.OUTER CASING(for mniti-cased wells)OR LINER lir ap llcable)
Carolina Well Drifting FROM TO DIAMETER _ THICKNESS MATERRI.
0 fL 62 fL 61/4 in' SDR21 PVC
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
24-130
2.Well Construction Permit 4: FROM TO DIAMETER THICKNESS M.tTEWAL
List all applicable well cantina-lionpermits(i.e. U1C County,State.Variance.etc) ft. ft. In.
3.Well Use(check well use): ft. ft. in
7.SCREEN
Water Supply Well:
FROM TO DI 1MF'fEN SLOT SI'LE THICKNESS MATERIAL
Agricultural )MunicipaVPublic ft. n. In.
)Geothermal(Heating/Cooling Supply) isaResidential Water Supply(single 1 1, it. ft. in.
JlndustrialiCommercial )Residential Water Supply(shared I r is.GROUT ^
"Irrigation I FROM Ti r MATERIAL. , EMPLACEMENT METHOD te AMUt'NT
Non-Water Supply Well: 0 t` 20+ f` Bentonite Pour(13)50Ib Bags
)Monitoring )Recovery ft. it.
Injection Well: It. It.
ID Aquifer Recharge )Groundwater Remediation
IS,SAND/GRAVEL PACK of applicable)
0 Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
1 ID Aquifer Test )Sto. water Drainage ft. rt.m
J Experimental Technology [Subsidence Control f ft. ft.
Geothermal(Closed Loop) )Tracer i 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION r cuter,hardness,sun/ruck type,grain size,Oct.
',Geothermal(Heating/Cooling Return) nOthcr(explain under#21 Remarks)
0 ft 6 rL Brown Clay
4.Date Well(s)Completed: 5-7-24 Well ID# 6 ft' 14 ft' Brown Shale RQgk
5a.Well Location: 14 ft' 400 ft. Blue Slate _
Matthew Charles St. Clair rt. ft. _ , . '
Facility/Owner Maine Facility 1DM(if applicable) tt ft
708 Greenfield Dr.Monroe 28112 rt. rt. AUG 2 7 20/4
R. fL i,
Physical Address,City,and Zip
Union 04-117-032 2i.REMARKS _.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: —
(if well field,one'at/long is sufficient) 22.Certification:
34.54.18 N 80.30.57 K, r
5-31-24
6.Is(are)the well(s)63Permanent or )Temporary Signature of Certified Well oauacwr Date
Hv signing this fount I hereby certify that the walls) was(were)constructed in accordance
7.Is this a repair to an existing well: )Yes or Eallo with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
)f this is a repair,Jill out known well construction information unJ raplain the nature of the copy of this record has been provided to the well owner.
repair minds,#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 details. You may also attach additional pages if necessary.
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 400 (ft.) 24a. For All Welk: Submit this form within 30 days of completion of well
For multiple nc//t list all depths if different(example-3@200'and 2®/00') construction to the following:
10.Static water level below top of casing: 38 (It-) Division of Water Resources,Information Processing Unit,
If hater keel is above caring.use•4-" 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (lit.) 24b.For Infection 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(glint) 7 Method or test: Air 24c.For Water Supply & Infection 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 to the county health department of the county
where constructed.
Form GW-1 North Carolina Department at Environmental Quality-Division of Water Resources Revised 2-22-2016