GW1--05112_Well Construction - GW1_20240827

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver 14.WATER ZONES
FROM TO DFSCRIPTIIIN
Well Contractor Name
86 ft. 117 ft-
3002-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATER!Al.
Company Name 0 ft. 44 ft' 61/4 in' SDR21 PVC
16.INNER C:%SING OR TUBING(geotherm al closed loop)
23-324
2.Well Construction Permit#: FROM TO DIAMETER 1lilt KNESS MATERIAL.
List all applicable well construction permits(i.e.WC,County,State,Variance,etc.) ft. ft. In.
3.Well Use(check well use): ft. ft. ill.
17.SCRF,EN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
®Agricultural OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) taResidential Water Supply(single) ft. ft, in.
O Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
',Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 20+ ft' Bentonite Pour(8) 501b Bags
Monitoring ORecovery ft. ft.
Injection Well: I.i It.
Aquifer Recharge OGroundwater Remediation ly.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery
Aquifer Test OSaliniry Barrier FROM TO MATERIAL EMIT_ACE\IENT METHOD
OSwrmwater Drainage It. ft.
OExperimental Technology DSubsidence Control ft. ft.
O Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DI;SCREPT1ON i color.hardness,soil/ruck type,grain size,ctc.l
OGeothermal(Heating/Cooling Return) nOther(explain under#21 Remarks)
0 ft. 6 ft. Brown Dirt
4.Date Well(s)Completed: 6-20-24 Well ID# 6 rL 18 IL Brown Clay/Shale
Sa.Well Location: 18 ft" 225 it Blue Slate
rt. rt. -�
Scott Byrum � i
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
5715 Little Staton Rd.Marshville 28103 ft. ft. AUG 2 12024
Physical Address,City,and Zip ft. Ft
r,
Union 01-174-002 21.REMARKS _
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.11.774 N 80.39.383 W
�j 6-28-24
6.Is(are)the well(s)10I'ernlanent or OTemporar} Signature of Certified Well Contractor Date
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: OYes or SINo with I5A 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 INSTRUCTIONS
9.Total well depth below land surface: 225 (B-) 24a. For All Wells: Submit this form within 30 days of completion of well
For nueltiplc went list all depths if different(example-3(d200'and 2(0100') construction to the following:
10.Static water level below top of casing: 29 (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 (i .) 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.c.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 fgpm) 4 Method of test: Air 24c.For Water SUDDIv &Injection 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: 15oz 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