GW1-2021-01714_Well Construction - GW1_20210323

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Infr mallon:
Frankie L. Oliver 14.WATER ZONES _
Well Contractor Narne FROM TO MtSCRIPI'ION
3002-A 193 ^' 241 ^•
NC Wen Contractor Certification Number 556 ^' 571 If
I&OUTER CASING for NIHtiY.are4 wrRr OR LINER V e
Carolina Well Drilling FROM TO DIAMFTF.R THICKNESS MATERIAI.
Coinpaoy Naive 0 ^' 44 ^' 61/8" In' I SDR21 PVC
20-525 16 B4NER CA IN R TU Gi 1 closed-lapporm
2.Well Construction Permit 9: FROM I TO I DIAMETERR THICKNPS.R I WWAIAL
Lin al!appliarble ne71 rnndnaalao perrnor(i.a.U1C,C,,aam Stare,Var.......etc.) ft. It. in.
3.Well Use(check well use): n. tt. in.
Water Supply Well: 17.SCREEN
FROM TO I DIAMETER RIA)I'VI"'/.R tHil:KNfSS MATERIAI,
Agricultural Municipal/Public 0 ft. ft, in.
Geothennal(Healing/Cooling Supply) ®Residential Water Supply(single) fL ft. Ia
Industrial/Commercial QResidential Water Supply(shared) I&GROUT
Iri ation FROM TO MATERIAL EMPLACEMENT MRTHOD@AMOUNT
Non-Water supply Well: 0 ^' 20+ ^' Bentonite Pour 16 50110 Bags
Monitoring Recovery n. n.
Injection Well: R. rL
Aquifer Recharge Groundwater Remediation 19.BANDH:RAVBL.P L' V ble
Aquifer Storage and Recover) Salinity Banner TO MMATERIALRM!"TACEMENTMITHOD
Aquifer Test QSformwater Drainage n. n.
Experimental Technology FROM Subsidence Control n. IT.
Geothermal(Closed lanp) QTracer 20.DRB•LINOI.OGatimbatldr ehnbifmc r
Geothermal lHealing/Copithng Remml rJO11cr rexloo under 821 Remarksl "'ROM To IUPSCa1PT10N I<ebr 6ardne¢.u,IVmr41 ramme or.l
0 D. 6 ^' Brown Clay
4.Dale Wells)Completed: 2-5-2021 Well IDS 6 ^' 30 ^' Brown Clay/Shale
5a.Well Location: 30 IT. 600 n. Blue Slate
Vladimir Podrez
FaciligdOwncr Hans Facility ID#lifappiwable) ^" ^- - - -
1416 Witmore Rd. Wingate 28174 ^' ^' 2
Phy<Ical Address.City,and Zip
n. n
Union 09-031-005 21.REMARKS
County Parcel Idcmificaion No (PIN)
5b.Latitude and longitude in degrees/mf vides/seci nds cr decimal degrees:
(if yell field one 1.01pa g is sufficicnn 22.Certification:
34.57.002 N 80.26.933 Wr ^-�')
C ' 3-1-2021
6.Is(are)the well(s)OPermanent or 1311'emporery Sigruwre ofCenified Well Contractor Date
Ry signing thia form, I hereby aertjj that the urll(r)noes lu'ere)emanm led in aemrdmme
7.Is this a repair to an existing well: Yes or Jallo n;th ISA NC'AC 02C.010O ar 15A NCAC 02C.0200 Well C..noaarpor Swndnrdr and that a
/f fhir is e repair,fill nth knonn axll ca¢trunion infornuttloo and explain the nn/are ofrhe cops r f this record hnr bean provided to the well minoo.
repair ander#21 rensarkx senior oron the Ma k ofihis fomt.
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
cun5lrVction,only I OW-1 is needed. Indicate T07 AL NUMBER of wells construction details. You may also attach additional pages if necessap.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 600 (ft.) 24a. For All Wells: Submit _his form within 30 days of completion of well
For,nsh,yoie iMps lid all depthr qdp rent(.sample-3C.200'cord 1C1o01 comimetion to the following:
10.Static water level below top of casing: 19 (ft.) Dlvlslon of Water Resources,Infonrmllem Processing Unit,
if"ater Leval d abo,e aa:rfnf,use.1 1. 1617 Mail Service Center,Raleigh,NC 27699•1617
11.Borehole diameter: 6 (In.) 24h. For Iniection Wells: In addition to sending the form to the address in 24a
Air Rotary above, also submit mu copy o1'this form within 30 Jays of completion of well
12.Well construction method: construction to the followingg.
(Lc.auger,rotary,cable,Jirat push,etc.)
Division ofWater Resources,Underground Irjeetion 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 Supply & Injection Wells: hi addition to sending the Joint to
the address(ns) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 70a/o HTH Amount. 36oz completion of well construction to the county health department of the county
where constructed.
Form GW-1 Nonh Carolina Depannient of Fn,warrerenml Quality-Division of Water Resources Revised 2-22-2016