GW1--05123_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 DESCRIPTION
Well Contractor Name
243 r` 282 f`
3002-A 517 rt. rt.
NC Well Contractor Certification Number IS.OUTER CASING(for mold-cased wells)OR LINER(If e)
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 45 ft 6 1/4 'n' SDR21 PVC
16.INNER CASING OR TUBING(geothermal sassed-tam)
2.Well Construction Permit#: 24-136 FROM TO DIAMETER THICRT'ESS MATERIAL
Lint all applicable well ennui-actionpermits(i.e. UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): [t tt in.
17.
Water Supply Well: FROMREEN TO DIAMETER SLOT SIZE -THICKNESS MATERIAL
©Agricultural QMunicipal/Public ft. rt. ' in.
in Geothermal(Heating/Cooling Supply) Residential Water Supply(single) n, n. ' in.
(]Industrial/Commercial DResidential Water Supply(shared) in.GROUT
(,Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20+ ft* Bentonite Pour(13)50Ib Bags
QMonitoring 0Recovery ft. rt.
Injection Well: rt. rt.
0Aquifer Recharge ()Groundwater Remediation
-
19.$AND/GRAVEL PACK(It applicable)
0 Aquifer Storage and Recovery 0Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test QStormwater Drainage rt re
Experimental Technology 0Subsidence Control ft ft.
0 Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
r]Creothertnal(Heating/Cooling Return) FROM TO DESCRIPTION(color.hardnaa,sail/ruck type,grain size,etc.)
g R ❑Other(explain under#21 Remarks)
0 ft. 8 r` Red Clay
4.Date Wells)Completed: 5-13-24 Well ID# 8 ft. 25 r` Brown Dirt/Rock
5a.Well Location: 25 [u 600 f- Blue Slate ,
Brian Sniatecki rt. rt.
Facility/Owner Name Facility ID#(if applicable) rt. rt. , , .-, i
4710 White Store Rd. Wingate 28174 rt. rt. lI�?
Physical Address,City,and Zip ft. rt. C�14
21.REMARKS lr,:`;:, .. )-_
Union 03-143-013 ,, ;
County Parcel Identification No.(PAN) •'•..
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/tong is sufficient) 22.Certification:
34.55.16 N 80.25.47 W ---� �27
Qom' 6-13-24
6.Is(are)the well(s)6aPermanent or OTemporary Signature of Certified Well Contractor Date
By signing this form, 7 hereby certify that the well(s) was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or ioNo with 1SA NCAC 02C.0100 or 1SA NC.4C 02C.0200 Well Construction Standards and that a
If this is a repair,fill out knows,well construction information and explain the nature of the copy of this record has been provided to the well owner,
repair under#2I remarks section or on the back of this fonn.
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: 600 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
Far multiple wells list all depths if different(eranaple•3(200'and 2(41001 construction to the tollowing:
10.Static water level below top of casing: 32 _(ft.) Division of Water Resources,Information Processing Unit,
7fwater level is above casing,use"+ 1617 Mail Service 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 & 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: 36oz 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