GW1-2021-04198_Well Construction - GW1_20210401

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information:
Frankie L.Oliver 14::WATERZONES" .Y, '
Well Contractor Name FROM TO DESCRIPTION
3002-A 147 n 170 f`'
373 fL 386 r`'
NC Well Contractor Certification Number 157oUTRR;CASING-for hWItl-t.a§ed',wells;OR L`1NER'ILe" livable'`
Carolina Well Drilling FROM TO DIAMETER THtCKNItSS MATERIAL
Company Name 0 ft 50 ft' 61/8" 1" SDR21 PVC
20-614 `.16-INNER`'CASING UR TUB1Ni:; eitbermal'closed-loo 4;'- .
2.Well Construction Permit#: FROM I TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) In.
3.Well Use(check well use): n. fL In.
Water Supply Well: FROM TO DIAMRTBR GSLOTSIZE 7HICKNES6 MATE Ell AI.
Agricultural [3Municipal/Public 0 fL fL In.
Geothermal(Heating/Cooling Supply) EaResidential Water Supply(single) fL fL In.
Industrial/Commercial Residential Water Supply(shared) „Ag;GROUT< ,x,,':, f
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 01. 20+ rL Bentonite Pour 17 501b Bags
Monitoring 1311ecovery ft. n.
Injection Well:
n. tL
Aquifer Recharge 13Groundwater Remediation
^;19:SAND'ltr A119GIRACK'if a llcable
_ Aquifer Storage and Recovery Salinity Barrier FROM I TO MATERiAL EMPLACEMENT MFTHOD n1*
Aquifer Test [3Stormwater Drainage n• ft'
Experimental Technology Subsidence Control n• It.
Geothermal(Closed Loop) Tracer :`20 DRIIsL1NGd OG`'titlech addltioti>tlieticets'lfnecessac :5.
FROM TO DESCRIPTION color,hardness soWrock t rein sin etc.
Geothermal(Hearin Conlin Return) Other(explain under#21 Remarks)
0 r` 21 rt Brown Dirt/Shale
4.Date Well(s)Completed: 3-17-2021 Well ID# 21 n' 300 Blue Slate
fL ft.
Se.Well Location:
Michael Kovalev n.
Facility/Owner Name Facility►D#(if applicable)
n. n.
VON
8845 Indian Trail-Fairview Rd. Indian Trail 28079 n n 1
Physical Address,City,and Zip n. +
Union 08-261-004E 21:REMIARKS'
•art ln,.
County Parcel Identification No.(PIN) " uN e..
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latAong is sufficient) 22.Certification:
35.60.950 N 80.34222 W 3-23-2021
6.Is(are)the well(s)oPermanent or 13Temporary
Signature of Certified Well Contractor Date
By signing this form, 1 hereby certify that the rvell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: C)Yes or 6&No will;15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information mud explain the nature of due copy of this record bar been provided to the well owner.
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 alsoattach 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 multiple wells list all depths if different(example-3@200'and 2(a 100') construction to the following:
10.Static water level below top of casing: 18 (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above caring,use"+" 1617 Mall Service Center,Raleigh,NC 27699.1617
11.Borehole diameter: 6 (in.) 24b.For Infection Wells: In addition to sending die 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) 12 Method of test: Air 24c.For Water Supply&Is leciion 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.
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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