GW1--05110_Well Construction - GW1_20240827

WELL CONSTRUCTION RECORD(GW-I) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
58 ft. 96 rt•
3002-A 171 ft' 190 ft'
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 44 it. 61/4 in' SDR21 PVC
Company Name
24-170 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable will construction permits(ie.U1C,County,State,Variance,etc.) rt. et. in.
3.Well Use(check well use): ft ft. in.
1Water Supply Well: R F SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
©Agricultural °Municipal/Public ft. ft. ill.
°Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
alndustrial/Commercial ()Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD Si AMOUNT
Non-Water Supply Well: 0 ft' 20+ ft. Bentonite Pour(12)501b Bags
°Monitoring °Recovery ft. ft.
Injection Well:
it. tt.
Aquifer Recharge ()Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery E3 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0 Stormwater Drainage
It. I't.
Experimental Technology DSubsidence Control ft_ it.
®Geothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION'color,hardness,soil/rock type,grain size,etc.)
°Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks)
0 ft' 6 ft Brown Dirt
4.Date Wells)Completed: 6-27-24 Well ID# 6 et' 22 et' Brown Clay/Shale
5a.Well Location: 22 ft' 200 ft Granite
Jeffrey&Carla Wallace rt ft. � '
AUG ?Facility/Owner Name Facility ID#(if applicable) rt. ft. / 2024
1107 Lester Mullis Rd. Indian Trail 28079 rt. ft.
-
Physical Address,City,and Zip ft. ft..
Union 08-246-004 21.REMARKS
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:
35.11.70 N 80.34.00 `,l, v�
6-28-24
6.Is(are)the well(s)�Permanent or [JTetnporary Signature of Certified Well Contractor Date
By signing this form. 1 hereby certify that the wells)was(were)constricted in accordance
7.Is this a repair to an existing well: E3Yes or Eallo with iSA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out brown 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 INSTRUCTIONS
9.Total well depth below land surface: 200 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For nudtiple wells list all depths if different(example-3(d�200'and2(41100') construction to the following:
10.Static water level below top of casing: 30 (il.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"-F" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Inflection 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) 30 Method of test: Air 24c.For Water Sunnly&inflection 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: 1 2oz completion of well construction to 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