GW1--05118_Well Construction - GW1_20240827

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
85 fr. 111 ft.
3002-A
132 ft. 163 ft.
NC Well Contractor Certification Number 15.OUTER CASING(for mold-cased wells)OR LINER(if applicable)
Carolina Well Drilling FROM TO DIAMETER THICKNESS MSTERI tI.
Company Name 0 ft. 43 ft. 61/4 `n' SDR21 PVC
24-215 16.INNER CASING OR TUBING(geothermal closed-loop)
2 Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. WC,County,State,Variance,etc.) ft. h. in.
3.Well Use(check well use): rt. h in.
Water Supply Well: 17.SCREEN
FROM TU DIAMETER SLOT SIZE THICKNESS NI t'I FAD SI.
°Agricultural °Municipal/Public ft. ft. in.
0 Geothermal(Heating/Cooling Supply) EIRecidential Water Supply(single) ff. II. in.
Industrial/Commercial °Residential Water Supply(shared) lx.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 20+ rt. Bentonite Pour(13)50Ib Bags
°Monitoring ()Recovery et. et.
Injection Well:
fL rt.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK Of applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO M STEM 1L EMPLACEMENT METHOD
0 Aquifer Test °Stormwater Drainage rt. ft.
°Experimental Technology °Subsidence Control ft. ft.
Geothermal(Closed Loop) QTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks FROM TO DESCRIPTION iculuq hardness,suil/ruck type,grain afar etc.)
0 ft 14 ft. Brown Dirt/Rock
4.Date Well(s)Completed: 7-22-24 Well ID# 14 I`' 300 I`' Blue Slate
5a.Well Location: It. ft. _ _
David&Cheri Hale It. It. r " S.
�'" 4 '�1..,d.
Facility/Owner Name Facility HA(if applicable) 1 t. it. A U!l] 2 7 2024
2526 Ajars Rd.Wingate 28174 ft. ft.
Physical Address,City,and Zip I t. f t. f
Union 02-192-003F 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:
34.54.54 N 80.23.47 W
8-6-24
6.Is(are)the wel(s)�Permanent or °Temporary 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: DYes or MNo with ISA NCAC 02C.0/00 or ISA 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 tooter#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: 300 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For nutltiple wells list all depths if different(example-3@200'and 2@I00) construction to the following:
10.Static water level below top of casing: 6 (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 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(gpm) 6 Method of 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: 18oz 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