GW1-2021-04199_Well Construction - GW1_20210401

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankje L.Oliver 14 WATER12ONEs .... :g_ 4 y
Well Contractor Name FROM To I•DESCRIPTION
3002-A 322 f< 383 f'
450 fa 572 ft.
NC Well Contractor Certification Number ;;15i4UUTF.R'CASINC:: or.fnaltl iieved:wepsyOR I INFR'IP a 1lcable',',
Carolina Well Drilling FROM TO DIAMETER THICKNRSS MATERIAL
0 ft. 44 ft 61/8" in' SDR21 PVC
Company Name
20-526 1#i`INNER-CASING!.OR=TUBING 'entbeFtnal closes-loo -_
2.Well Construction Permit#• FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) rL h• in
3.Well Use(check well use): ft• fL lo.
Water Supply Well:
FROM TO DIAMETER Sr OT S17.E THICKNESS MATERIAL
Agricultural [3Municipal/Public 0 ft. rL In.
Geothermal(Heating/Cooling Supply) SaResidential Water Supply(single) fL fL in.
Industrial/Commercial 13Residential Water Supply(shared)
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD lh AMOUNT
Non-Water Supply Well: 0 fL 20+ fL Bentonite Pour 17 501b Bags
Monitoring Recovery ft, ft.
Injection Well: fL fL
Aquifer Recharge Groundwater Remediation
/GRAVE L"PA'CK If a i'licable '
Aquifer Storage and Recovery Salinity Barrier FROM I TO MATERIAL FTfPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage n• ft.
Experimental Technology 13Subsidence Control n• ft
Geothermal(Closed loop) Tracer a20 DRILLINGLOG°;ettti8h'tiddltioneRshects lfnecesser k-''' '
FROM TO DESCRIPTION(color,hardness soil/rock t rein sire etc.
Geothermal(Hearin Conlin Return Other(explain under#21 Remarks)
0 f' 6 f4 Brown Clay
4.Date Well(s)Completed: 2-12-2021 Well m# 6 ft. 31 rL Brown Dirt/Shale
Sa.Well Location: 31 fL 650 ftSlate
Vladimir Podrez ft. fL
Facility/Owner Name Facility ID#t(if applicable) ft ft r
1408 Witmore Rd.Wingate 28174 Lot#3 rt. rt
Physical Address,City,and Zip ft.
Union 09-031-005
,at;o1�Pro�e
County Parcel Identification No.(PIN) DV
` 1 .. .
5b.Latitude and longitude in degrees/nilnutes/seconds or decimal degrees:
(if well field,one lat/tong is sufficient) 22.Certification:
34.57.044 N 80.26.913 W
3-1-2021
6.Ware)the well(s)ioPermanent or 13Temporary Signature of Certified Well Contractor Date
By signing this form, I hereby certify that the ovil(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or Jallo mith 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 in formation and explain the nature of the copy of this record has been provided to the well ouner.
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 1 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: 650 (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2@1001 construction to the following:
10.Static water level below top of casing: 18 (N Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.)
24b.For Infection 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) 20 Method of test: Air 24c.For Water Suoaly &Iniectfun Wells: In addition to sending the forni to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 70%HTH Amount: 40oz completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2.22-2016