GW1-2021-01716_Well Construction - GW1_20210323

WELL. CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L. Oliver 14.WATER ZONES
Well Contractor Name Flora I TO DFSCRIPTION
3002-A 111 f• 280 tt'
n. n.
NC Well Contractor Cenificarion Number 15.01FTER CASING(for multi-eased wells)OR LINER V a Hnble
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAI.
Company Name 0 n. 1 50 n• 61/8" in. SDR21 PVC
20 448 16.INNER CASING OR TUBING 1 eorbermal closed-Im
2.Well Construction Permit M: FROM TO DIAMETER THICKNESS MATERIAI.
Lkr a(I applimb(c well mnsrruonon permits G.e.UIC,Cmmry,State,Variance,etc) fl. n.
3.Well Use(check well use): n. n.
Water Supply Well: 17.SCREEN
FROM TO DtaMITER SLOT SIZE l'HICKM1'ESS AfATN:RIAV
Agricultural ®Municipal/Public 0 n. ft. in.
Geothermal(heating/Cooling Supply) ®Residential Water Supply(single) ft
Industrial/Commercial OResidential Water Supply(shared) I&GROUT
IIIj fltion FROM TO MATERIAL EMPLACEMENT METHOD kAMOUNT
Non-Water Supply Well: 0 rf• 20+ rt• Bentonite Pour 64 501b Bags
O R Monitoring ecovery
Injection Well: n. ft.
Aquifer Recharge ©Groundwater Remediation
19.SAND/GRAVEL PACK ft f xvplivable
Aquifer Storage and Recovery ®Salinity Barrier FROM TO MATERIALRM1IPLACEMENT METHOD
Aquifer Test �Slormwater Drainage ft.
fL
Experimental Technology ❑Subsidence Control
Geothernal(Closed Luoto ©Tracer 20.DRILLING LOG lunch additional sheers if necessa
DFSCRIP'1'ION(mloq hardness,mlVrock I u,etc.)
Geothermal(Hearin Conlin ReReturn) Other(explain under k21 Remarks) FROM to
0 tt' 6 tt' Red Clay
4.Date Well(s)Completed: 3-5-2021 Well ID4 6 ft' 42 n' Brown Clay/Rock
So.Well Location: 42 ft. 300 f4 Blue Slate
Tanner Design&Build n. n.
Facility/Owner Name Facility rD#Ufapplicable) ft. n.
3507 Tom Greene Rd. Monroe 28112 ft. ft. QZ
Physical Address,City,and Zip ft. ft. t _
Union 04-291-004P 21.REMARKS
County Parcel Identification No (PIN) -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(,I well field,one IaVlong is sufficient) 22.Certification:
34.84.831 N 80.63.430 W, —
3-16-2021
6.Ls(m•e)the well(s)OPermmmenl or Temporary Srgnatme of Cemfied Well Contractor Date
Sp stern,this farm, I hereby eertif-that the wr(ll r)uuc(were)r n,"w"ed io ennrdmax
7.Is this a repair to an existing well: Yes or ®No x'irh 15A NCAC 02G.011N)ar 15A NCAC 02C.029)Well C..aouawn Stmolarda and that a
IPhu u a repub,fill ma known well mnstruetion information and e,1....rim noon a of the cop)of this reoorrI hair been pro ukd m the well miner.
repair under N27 rema*s senior or on rhr back of this fmar.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loup Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only I GW-I 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 (ftd 24a. For All Wells: Submit this form within 30 days of completion of well
Far awhlple o,11s lin all depths fdtfferent(esnrnplr-3@200'ar d 2C.100) construction to the following:
10.Static water level below top of casing: 10 (ft.) Division of Water Resources,Information Processing Unit,
fomrr level m above caving, ,,,"- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24h. For Infection Wells: In addition to sending the form to the address in 24a
Air Rota above.also submit one copy of this form within 30 days of completion of well
(i.a re Well construction method: fY auger,meaty,cable,direct push,etc.) cunstmernm I.the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 7 Method of test: Air 24c.For Water Supply & Injection Wells: In addition to sending the form to
the addresses) above, also m nnit 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 GWA North Carolina Depannienl of Envio n acnml Quality-Division of Water Resources Revised 2-22-2016
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