GW1-2021-06785_Well Construction - GW1_20210809

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver 1a.wATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3002A 120 et• 136 fO
fL ft.
NC Well Contractor Certification Number „15:OUTER CASING(for multi-cased'wells)OR LINER if,ap--Itcable)
Carolina Well Drilling 65 6 1/$R THICKNESS MATERIAL FROM TO DIAMETF.
eL fL , i"' SDR21 PVC
Company Name
20-612 16.'INNER'CASING OR TUBING( eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 41—.SCREEN
FROM TO a DIAMETER • SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public ft. M in.
Geothermal(Heating/Cooling Supply) 13Residential Water Supply(single) fL ft. in.
Industrial/Commercial Residential Water Supply(shared) 748.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20+ ft Bentonite Pour 24 501b Bags
Monitoring ORecovery eL ft.
Injection Well: tt ft.
Aquifer Recharge []Groundwater Remediation 19$AND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage
ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) 0TraCer '.20'DRILLING:LOG:(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness soiltrock type, rain sim,etc.)
Geothermal(Heating/Coolin Return) Other(ex lain under#21 Remarks)
0 ft. 6 �' Red Clay
4.Date Well(s)Completed: 5-20-2021 Well ID# 6 ft' 14 "' Brown,Clay/Shale
5a.Well Location: 14 ft. 21 ft. Brown Rock
James R. Mullis 21 ft' 700 fL Blue Slate
Facility/Owner Name Facility ID#(if applicable) ft. fl.
610 Belmont Church Rd. Monroe 28112 ft. ft. a ��
Physical Address.City,and Zip
Union 09165002A 2I:=REMARICs -5
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:
34.56.578 N 80.31.351 W
'� 6-4-2021
6.Is(are)the well(s) Permanent or OTemporary Signature of Certified Well Contractor Date
By signing this(onn, I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or RNo N'ilh 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Smndardr 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 ouvier.
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 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: 700 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: 28 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 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) 11 Method of test: Air 24c.For Water Suoaly&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.
4
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016